^ r,:' ;■ UC-NRLF lllllli iiiiiie III B ^ WDD ^DS Donnis Chinn, O.D. 2100 E. Clinton Ave. fn$no, Ca. 93703 - 224-8300 NORMAL FUNDUS. LESSONS ON THE EYE FOR THE USE OF UNDERGRADUATE STUDENTS BY FRANK L. HENDERSON, M. D. EX-PRESIDENT OF THE ST. LOUIS MEDICAL SOCIETY (1905); CHAIRMAN OF THE OPHTHALMIC SECTION OF THE ST. LOUIS MEDICAL SOCIETY (iQIo); OPHTHAL- MIC SURGEON TO ST. MARY's INFIRMARY; CONSULTI.N'G OCULIST TO the wabash railway; member op the american medical association; member op the Missouri state medi- cal association; MEMBER OP THE AMERICAN ACADEMY OF OPHTHALMOLOGY AND OTO-LARYNGOLOGY, ETC. FOURTH EDITION, REVISED PHILADELPHIA P. BLAKISTON'S SON & CO 1012 WALNUT STREET 1911 ^5 V i> ofnmam uBwn Copyright, ioio, by P. Blakiston's Son & Co. Printed by The Maple Press York, Pa. ') Op I PREFACE TO FOURTH EDITION In revising this little book the original purpose of making it a substitute for the student's classroom notes has been adhered to. With the ever-increasing volume of ophthalmic knowledge this has become more difficult. The surcharged specialist will be able to detect many omissions. Some of these omissions may not have been intentional. HuMBOi-DT Building, St. Louis, Mo. 1802 PREFACE TO THIRD EDITION. Student's manuals on diseases of the eye are, as a rule, either exhaustive treatises in fine print or con- densations of the entire science of ophthalmology. The authors of these works seem loath to omit any knowl- edge which, as specialists, they have acquired. The result is that subjects which the general practitioner never attempts to master are given as much space as those with which he should be familiar. It should be the purpose of a medical school to provide its graduates with an equipment which will best meet the demands of general practice, and I recognize that there is enough matter to fill the course to overflowing, that is of more importance than the layers of the retina or the formula for calculating the index of refraction of a transparent medium. The only claim to originality made for this work lies in its omissions. Minute anatomy, the fitting of glasses, skiascopy, ophthalmoscopy and kindred subjects have been left out intentionally, as I believe they belong to post-graduate instruction. I have also slighted those diseases which have to be diagnosed with the ophthalmoscope, as I doubt the diagnostic value of an ophthalmoscope in the hands of the average practitioner. It is not my desire to minimize medical education but rather to increase the useful knowledge of the vii Vlll PREFACE TO THIRD EDITION. graduate by selecting that which will be of the most service to him, at the same time giving him as much as the undergraduate student • can reasonably be expected to learn in the limited time allotted to the eye in our medical schools. The use of these printed notes enables the teacher to devote much time to quizzing which would otherwise be spent in lecturing. They also enable the student to dispense with his inaccurate and misleading classroom notes. The subject has been divided into twenty-eight lessons, or one lesson for each week of a seven months' session. In the spelling of such words as oxid, quinin, morphin, sulfate, etc., the rules adopted in 1891, by the American Association for the Advancement of Science, have been followed. CONTENTS. LESSON I. ANATOMY. The Orbits; Ocular muscles; Lids. LESSON IL ANATOMY {continued). The Lacrymal apparatus; Conjunctiva; Eyeball; Cornea. LESSON in. ANATOMY (continued). The Sclera; Iris; Ciliary body; Choroid. LESSON IV. ANATOMY (continued). The Lens; Vitreous; Retina; Optic nerves. LESSON V. OPTICS. Light; Refraction; Prisms; Lenses. Convex lenses; Concave lenses; Cylindric lenses. LESSON VI. REFRACTION AND PHYSIOLOGY. Emmetropia; Accommodation; Presbyopia; Convergence Field of vision; Color perception. X CONTENTS. LESSON VII. ERRORS OF REFRACTION. Ametropia; Hyperopia; Myopia; Astigmia; Isometropia; Anisometropia; Antimetropia. LESSON VIII. DISORDERS OF THE OCULAR MOVEMENTS. Strabismus; Paralytic strabismus. LESSON IX. DISORDERS OF THE OCULAR MOVEMENTS {cOVltiuued) . Comitant strabismus; Insufficiency of the ocular muscles; Nystagmus. LESSON X. DISEASES OF THE LIDS. Blepharitis; Hordeolum; Chalazion; Trichiasis; Entropion and ectropion; Ankyloblepharon. LESSON XI. DISEASES OF THE LIDS (cOlltinued). Blepharospasm; Lagophthalmia; Ptosis; Eczema; Herpes zoster ophthalmicus; Phthiriasis; Ecchymosis of the lids; Rodent Ulcer; Sarcoma; Erysipelas; Lupus; Syphilitic ulcer. LESSON XII. DISEASES OF THE LACRYMAL APPARATUS. Diseases of the lacrymal gland; Anomalies of the puncta and canaHculi; Chronic dacryocystitis; Acute dacryocys- titis. LESSON XIII. DISEASES OF THE ORBITS. Meningocele; Periostitis; Caries and necrosis; Hyperostosis; Periostosis; Exostosis; Injuries; Orbital cellulitis; Tumors; Pulsating exophthalmos. CONTENTS. XI LESSON XIV. DISEASES OF THE CONJUNCTIVA. Catarrhal conjunctivitis; Chronic catarrhal conjunctivitis; Purulent conjunctivitis; Membranous conjunctivitis. LESSON XV. DISEASES OF THE CONJUNCTIVA (continued). Granular conjunctivitis or trachoma; Acute trachoma; Follicular conjunctivitis. LESSON XVL DISEASES OF THE CONJUNCTIVA (continued). Vernal conjunctivitis; Pterygium; Pinguecula; Symbleph- aron; Burns; Sub-conjunctival ecchymosis; Morbid growths in the conjunctiva. LESSON XVIL DISEASES OF THE CORNEA. Phlyctenular keratitis; Interstitial keratitis. LESSON XVIII. DISEASES OF THE CORNEA (continued). Ulceration of the cornea. LESSON XIX. DISEASES OF THE CORNEA (continued) AND SCLERA. Vascular keratitis or pannus; Opacities of the cornea; Staphyloma; Arcus senilis; Conical cornea; Foreign bodies in the cornea; Episcleritis; Scleritis. LESSON XX. DISEASES OF THE IRIS. Mydriasis; Myosis; Iritis; Plastic iritis; Suppurative iritis; Serous iritis. Xii CONTENTS. LESSON XXI. DISEASES OF THE CILIARY BODY AND VITREOUS. Plastic and suppurative cyclitis; Serous cyclitis; Sympa- thetic Ophthalmia; Muscae volitantes; Opacities of the vitreous; Hemorrhage into the vitreous; Foreign bodies in the vitreous. LESSON XXIL DISEASES OF THE CHOROID. Plastic choroiditis; Disseminate choroiditis; Central cho- roiditis; Syphilitic choroido-retinitis; Myopic choroid- itis; Purulent choroiditis; Pseudo-glioma; Panophthal- mitis; Rupture of the choroid. LESSON XXIIL GLAUCOMA. Secretion and excretion of intra-ocular fluid; Tension; Simple glaucoma; Acute glaucoma; Absolute glaucoma; Secondary glaucoma. LESSON XXIV. DISEASES OF THE CRYSTALLINE LENS. Dislocation of the lens; Cataract; Aphakia. . LESSON XXV. DISEASES OF THE RETINA. Hyperemia and anemia; Retinal change from direct sun rays; Snow blindness; Electric ophthalmia; Embolism and thrombosis; Retinitis; Albuminuric retinitis; Dia- betic retinitis; SyphiUtic retinitis; Hemorrhagic retinitis; Retinitis pigmentosa; Detachment of the retina; Glioma of the retina. CONTENTS. Xlll LESSON XXVI. DISEASES OF THE OPTIC NERVE. Papillitis; Retro-bulbar neuritis; Quinin amblyopia; Atrophy of the optic nerve. LESSON XXVIL FUNCTIONAL DISORDERS OF VISION. Amblyopia and amaurosis; Amaurosis partiaHs fugax; Hemianopsia; Nyctalopia; Hemeralopia. LESSON xxvin. GENERAL THERAPEUTICS. Heat; Cold; Anesthesia; Mydriatics; Cycloplegics; Myotics; Antiseptics and disinfectants; Stimulants and astrin- gents; Ointments; Miscellaneous remedies. LESSON I. ANATOMY OF THE EYE. THE ORBITS. These four-sided, pyramidal or conical cavities, a little over an inch and a half deep, are formed by seven bones: frontal, sphenoid, ethmoid, superior maxillary, ])alate. malar and lacrymal. On the inner wall of the Fig. I. — Left orbit. orbit is the groove, formed by the lacrymal bone and the nasal spine of the superior maxillary, in which is lodged the lacrymal sac. In front of this groove is the insertion of the orbicularis, the muscle which closes the I 2 LESSONS ON 'IHE EYE. eyelids, and l>ehind the groove is the insertion of the tensor tarsi or Horner's muscle which holds the lids close to the globe. In the angle formed by the roof of the orbit and the nasal wall, and a short distance be- hind the orbital rim, is the loop or pulley through which passes the tendon of the superior oblique muscle. In the angle formed by the roof and the temporal wall and just under the edge of the orbit is a fossa which holds the lacrymal gland. At the junction of the inner and middle thirds of the superior orbital rim is the supra- orbital notch or foramen through which passes the supra- orbital nerve, artery and vein. Below the infra-orbital rim is the infra-orbital foramen, which is the termination of the canal of the same name. Near the apex of the orbit and between the great and lesser wing of the sphenoid bone is the sphenoidal fissure, which transmits the third, fourth, the ophthalmic division of the fifth and sixth nerves and the ophthalmic vein. The apex of the orbit corresponds to the optic foramen, a cylin- drical canal in the lesser wing of the sphenoid bone, which transmits the optic nerve and ophthalmic artery. Extending forward and outward from near the apex is the spheno-maxillary fissure. It lies between the lower border of the gi-eat wing of the sphenoid bone and the maxillary bone, and transmits the infra-orbital vessels and several nerves. In the middle of the orbital floor is the infra-orbital groove which terminates in the infra-orbital canal. The bones are covered by perios- teum and the orbital space not filled by the eyeball, nerves, muscles and vessels, is occupied by fat and connective tissue. This connective tissue becomes thickened in parts so as to form sheaths for the muscles ANATOMY OF 1111 and optic ncr\-c. It also dcx'clops a nu'iiihraiu' which spreads over the eyeball, from the entrance of the o])tic nerve to within three millimeters of the cornea, where it becomes inseparably mingled with the conjunctiva. This membrane is called Tenon's capsule. It is loosely connected to the episclera, the space between them serving as a lymph channel. The ophthalniic arlcry, a branch of the internal carotid, supj)lies l)lood to the orbit and its contents. Viv,. 2. — The ocuhir muscles seen from above, a, Superior ol)lii|ue; h, superior rectus; c, ixlernal rectus; (i, internal rectus; e, optic nerve; f, pulley of su])Crior oblique; ,tf, o])ti(Kimmissure. THE OCl^LAR MUSCLES. The ocular muscles are six in number, the internal, external, superior and inferior recti, and the superior 4 LKSSONS OF THE EYE. and hiferior oblique. All except the inferior oblique arise from the apex of the orbit around the optic fora- men. The inferior oblique arises from the floor of the orbit, in a slight depression in the superior maxillary- bone, near the lacrymal groove. All the ocular muscles, after piercing the capsule of Tenon are in- serted in the sclera, the four recti at points varying from 5 . 5 to 7 . 5 millimeters from the cornea. Fig. -Muscles of the left eve. Though the superior oblique arises at the apex of the orbit, the direction of its force is changed by passing through the pulley, before mentioned, which is situated in the angle formed by the roof and the nasal wall of the orbit. From this pulley its direction is backward and outward and passing under the superior rectus, it is inserted into the outer side of the globe, more than half ANATOMY OK IHl'. lOYE. 5 of the tendon being inserted haek of the e(|uat()r. The inferior obHque runs backward and outward, and ])ass- ing between the orlntal floor and the inferior rectus, it is inserted into the outer side of the globe, more than half of the tendon being back of the equator at a ])oint below the superior oblique. In addition to its scleral attachment, some fibers from the superior rectus and its sheath pass to the conjunctival fornix and to the to]i of the tarsus, bv which means these structures are Fig. 4. — The eye muscles seen from in front. mo\'ed in harmony with the upward mo\'ement of the eyeball. The termination of the inferior rectus is similar to that of the superior. In the same way fibrous bands are given oft" from the sheaths of the internal and external recti and pass laterally to the bones and soft parts of each side of the orbit. The levator palpebrcB siiperioris muscle, which lifts the upper lid, owing to its location, is best described with the ocular muscles. LESSONS ON THE EYE. It arises at the apex of the orljit and passes forward just under the roof of the orbit to its insertion into the top of the superior tarsus by a fan-shaped aponeurosis, which is as broad as the hd itself. The motor muscles of the eye are supplied with blood by the muscular branches of the ophthalmic artery. The external rectus muscle is supplied by the sixth nerve, the superior oblique by the fourth nerve, and the four remaining motor muscles, as well as the levator palpebrae superioris by the third nerve. THE LIDS. Under the skin of the lids is a thin layer of connective tissue, and under this the fibers of the orbicularis muscle. The orbicularis, which closes the lids, may be divided into a palpebral part which lies in the lids proper and an orbital portion which mingles with the muscles of the forehead and cheek. The former arises from the inter- nal palpebral ligament, the latter from the bones in front of the lacrymal groove. The tensor tarsi, or Horner's muscle, which is sometimes considered a part of the orbicularis, arises from the lacrymal bone behind the groove. Both of these muscles are supplied by the portio dura of the seventh or facial nerve. Under the orbicularis are the tarsi, formerly called cartilage, now known to be dense fibrous tissue. There is one of these thin, flat, elongated plates in each lid to give it form and support, the tarsus of the upper lid being twice as wide as the tarsus of the lower. The tarsi are connected at their extremities and also bound to the subjacent bone by the internal and external palpebral ligaments. ANATOMY OF IHE EYE. Fig. 5. — ^\'ertical section through the upper eyelid. A, Cutis; i, epi- dermis; 2, corium; B and 3, subcutaneous connective tissue; C and 7, orbic- ularis muscle; D, loose submuscular connective tissue; E, insertion of H. Miiller's muscle; F, tarsus; G, conjunctiva; J, inner, K, outer edge of the lid; 4, pigment cells; 5, sweat-glands; 6, hair follicles; 8 and 23, sections of nerves; 9, arteries; 10, veins; 11, cilia; 12, modified sweat-glands; 13, circular muscle of the Riolan; 14, Meibomian gland; 15, section of an acinus of the same; 16, posterior tarsal glands, submuscular connective tissue; 21 and 22, conjunctiva, with its epithelium; 24, fat; 25, loosely-woven pf)Steri()r end utolh.eZit.cyru Spender Jridis 'Zmula-ZuuiA ^^ ' VPro, Fig. 42. — The left half represents the eye at rest; the right, during arconi- modatiiMi. blurred. Now if the vision be concentrated upon the pencil its outline will become distinct and the image of the building will be blurred. This instantaneous difference in the vision is effected by the power which the eye has of changing its focus for different distances. We have seen that an emmetropic eye, in a state of rest, will focus upon its retina, all objects at a distance of twenty feet or over; that is, objects which emit parallel rays. RKI'RACTION AND I'HVSIOI.OCY OF THK KYK. 47 Rays from a near object are dix'erji^ent, theretore, an emmetropic eye must increase its focal power to have distinct vision of a near object, as it not only has to focus parallel rays, but has first to make the diverg- ence parallel. This is accomplished by contracting the circular or equatorial fibers of the ciliary muscle. Contraction of the ciliary muscle relaxes the suspensory ligament and capsule of the lens. When the pressure of the capsule is relieved the lens becomes more convex by an inherent elasticity. Increase in its convexity increases its focusing power. This power the eye })ossesses of increasing its focal strength is called accom- modation (Fig. 42). PRESBYOPIA. The elasticity of the crystalline lens diminishes gradually from childhood to old age. Under normal conditions this loss of elasticity is not felt until about the forty-fifth year, but at this period the power of accommodating is so lessened that convex glasses have to be resorted to for near vision. This physiologic loss of accommodative power is called presbyopia. Weak- ness of the ciliary muscle is also a contributing factor in presbyopia, particularly in old age. As accommoda- tion diminishes the reading glass must be strengthened, necessitating a change about every two years. CONVERGENCE. When an eye is directed toward an object so that the image of the thing looked at falls upon the fovea cen- tralis, the eye is said to fix that object. Normally both 48 LESSONS ON THP: EYE. eyes fix the same object, and in order to do this when it is brought near to the face, both eyes have to turn inward; the nearer the object the more the eyes turn in. The turning in of the eyes necessary to fix near objects is called convergence. FIELD OF VISION. When the eye is fixed on an object, other things besides the one looked at are visible. Those nearest Fig. 43. — Field of vision of a right eye. The arrow at o being fi.xed (looked at) all objects on the temporal side within the area described by about 95 degrees of a circle are visible; all objects on the nasal side within about 48 degrees are visible. The nasal side of the field is restricted by the l)ri(lgc of the nose. the one fixed are most di.stinct and the greater the distance of an ol)icct from the one rtxed, the less dis- tinctly is it seen. That area in which objects are \isible. the eye being fixed, is the field of vision. It will be RKFRAt'TIOX AND PHVSI01.()(;Y OF THK KVK 4'; seen from Fig. 43 that the nasal fidtl oi each eye ex- tends to about 48 degrees from the object looked at, therefore if both eyes look at the same object there is an overlapping of the two fields, or an area that is common to both eyes. This area which extends to about 48 degrees on each side of the object is called the binocular field of vision. COLOR PERCEPTION. A ray of sunlight passed through a ]nism and pro- jected upon a screen forms a band of colors ranging from red to violet. The red is toward the apex and the violet toward the base of the prism. Between the Fig. 44. — B is a screen which inlenepts all rays of light except the ray A. The prism C separates the ray .\ into the simple colors, red, orange, yellow- green, blue and violet, which are thrown on the screen D. The violet rays, if passed through the screen D, and prism E, would show on the screen F, as violet ; no further rlisintegration taking place. red and violet there are gradations of orange, yellow, green, and blue. The wave lengths of these colored rays gradually decrease from the red rays which are 0.000760 mm., to the violet, which are 0.000397 rnm. The greater the wave length of a ray of light, the less 4 50 LESSONS ON THE EYE. it is deviated by passing through a medium of different density, hence the power of a prism to separate a ray of white hght into its elements. The six colors of the solar spectrum, red, orange, yellow, green, blue and violet, are called simple colors because it is found by passing any one of them through a prism that no fur- ther disintegration takes place (Fig. 44). Red, green, and violet can be mixed to produce any of the other colors, but as no combination can produce either of these three they are called the primary colors. Fig. 45. — A diagram of color perception, i, Red; 2, green; 3, violet. The height of the curve from the base line indicates the proportions in which the primary colors are mixed to produce the simple colors of the spectrum, red, orange, \-ello\v, green, blue and violet. Many theories have been offered to explain the phenomenon of color perception, but none has yet sup- planted the Young- Helmholtz. This is that we have three primary color perceptions corresponding to the three primary colors of nature, and that there are red perceptive fibers, green perceptive fibers and violet per- ceptive fibers in our retinas. These different nerve fibers are stimulated by light waves of different lengths. Equal stimulation of all three produces the sensation of white, and just as all the colors in nature can 1)e pro- RKFRACTION AND I'll VSIOI.OGV OF THE EYK. 51 duced by mixing the spectrum red, green and \iolet, so can every color sensation be produced by stimulation of the red, green, and violet perceptive fibers in varying proportions. The absence or imi)airment of one or more of the primary perceptions constitutes color-blind- ness; the characteristic of the defect depending upon which element is missing or impaired. The theory of Eldridge-Green assumes that there is a color perceiving center in the brain and that defective color perception is the result of imperfect development of this center. Congenital color blindness does not disturb vision, is not dependent upon any demonstrable pathologic lesion, is irremediable and is often hereditary. There are other forms of color-blindness depending upon diseases of the retina and optic nerve, which will be described in con- nection with those diseases. LESSON VII. ERRORS OF REFRACTION. AMETROPIA. Any variation from the state of normal refraction or emmetropia is called ametropia. Ametropia appears in three forms : hyperopia, myopia and astigmia. Pres- byopia is not considered a form of arrietropia as it is a physiological change which overtakes the emmetropic as well as the ametropic eye. HYPEROPIA. If the focus of parallel rays is at an imaginary point behind the retina, the eye being at rest (z. e., not accommodating) , it is far-sighted or hyperopic. Hyper- opia is due to shortness of the antero-posterior axis of the eyeball or to lack of sufficient focal strength in the cornea and lens (Fig. 46) . As the fovea centralis lies between the dio])tric media of the hyperopic eye and their principal focus, rays of light from the fo\-ea, after passing through the lens and cornea, will be divergent (Fig. 32). If rays from the fovea are divergent when they lea\-e an eye only rays similarly conx'crgent upon entering it will be brought to a focus on the fovea. There are no convergent rays in nature, for as we ha\-e already learned those from 20 feet or more are parallel and those from a point less than 20 feet are divergent. 52 ERRORS OF RKl'RACTION. 53 There are but two ways of con\erging the rays of nature so as to focus them u])()n the retina of the hyperopic eye. The eye must increase its focal strength or rays must l)e artificially converged l^efore entering it. By accommodating, the lens can increase its focal strength, therefore hypero])ic eyes accommodate con- FlG. 46. — The upper figure shows parallel rays of light forused Ijehind the retina as in hyperopia. The lower figure shows the influence of a convex lens in bringing the focus to the retina. stantly for distant vision and for near vision must add the amount of accommodation exercised for distance to the amount it would accommodate if it were em- metropic. The continuous contraction of the circular fibers of the ciliary muscle required by the accom- modative effort of the hyperopic eye causes a number of symptoms, the most prominent of which is headache. See asthenopia, page 70. Rays may be artificially con\-erged before entering a 54 LESSONS ON THE EYE. hyperopic eye by the use of a convex lens, and thus brought to a focus on its fovea centrahs without any accommodative effort (Fig. 46) . MYOPIA. If the frcus of parallel rays is at a point in front of the retina, the eye being at rest, it is near-sighted or F"iG. 47. — The upper figure shows parallel rays of light focused in front of the retina as in myopia. The lower figure shows the influence of a concave lens in moving the focus back, to the retina. myopic. Myopia is due to too great length of the antero-posterior axis of the eyeball, or to too great focal strength of the cornea and lens (Fig. 47). As the fovea centralis lies farther from the dioptric media of the myopic eye than their principal focus, rays of light from the fovea, after passing through the lens and cornea, will be convergent and will come to a focus in front of the eye (Fig. 31). If rays from the fovea are KRRORS or REFRACTION. 55 convergent when they leave an eye only rays similarly divergent u])()n entering it will he hrought to a foens on the fo\-ea. Only rays from an ohject less than 20 feet are divergent, hence distant objects are seen poorly by a myopic eye and if its error is pronounced they are not seen at all. There is no way of decreasing the focal strength of the lens, therefore no effort on the part of a myope can overcome his defect. It can be overcome, how^ever, by artificially diverging rays before they enter the eye. This is accomplished by the use of concave lenses (Fig. 47)- The myopic eye is adjusted for near vision since only divergent rays can be focused on its retina and rays from near objects only are divergent. Hence the term near sight. The greater the degree of myopia the greater the degree of divergence which rays must have in order to focus on the fovea, and consequently the greater the myopia the nearer an object must be brought to the eye to see it distinctly. In hyperopia the effort of accommodation neces- sitates the constant exercise of the circular fibers of the ciliary muscle, and we find in hyperopic eyes that the circular fibers (Muller's muscle) are increased in size and number as in Fig. 48. Accommodation would make the vision of a myopic eye worse, and we find in these eyes that the circular fibers of the ciliary muscle are small in size and number. In myopia of high degree, when the vision of the patient is not sufficient for his needs and no condition exists contraindicating the operation, removal of the 5^ LESSONS ON THE EYE. crystalline lens may be resorted to. This jjroeedure has often given most gratifying results. It will be seen from what has preceded that (without lenses) the emmetropic eye sees distant objects in a state of rest (without accommodating) and must ac- Sriickes mujcla Orbici/Iits ciliaris. P'lG. 48. — Ciliary body of a hyperopic eye. (After Iwanofl'.) commodate for near objects; the hyperopic eye must accommodate to see both distant and near objects; and the myopic eye sees distant objects imperfectly or not at all and near ones without accommodating unless the myo])ia is of low degree. ASTIG.MIA. In emmetropia, hyperopia and myoina, the curva- ture of the cornea is the same in e\erv meridian, and its KRRORS ()|- RK FRACTION. 57 refractinj^- ])()wcm- is the sanu' ihrcms^^li o\-ery }xirt, \-er- tical, horizontal and ol)Hque. All rays that enter these eyes are brought to a common focus. Sometimes the cornea has meridians of dififerent curvature j^roducing greater refraction in some meridians than in others. Such a condition constitutes astigmia. In astigmia the rays passing through the meridian of greatest refraction reach their focus nearest the cornea, while ■■ ■ I Fig. 49.— Appearance of lines running in diffeient directions. \, as seen hy the normal eye; R, as seen by the astigmic eye. (Jackson.) those passing through the least refracting meridian come to a focus farthest back. The meridians of high- est and lowest refracting power are at right angles to each other and are called the principal meridians. As- tigmia is sometimes due to unequal curvature of the meridians of the crystalline lens or to an oblique posi- tion of the lens with regard to rays entering the pupil. Astigmia may be simple, compound or mixed. When one of the principal meridians is emmetropic and the other hyperopic or myopic, the astigmia is simple. When both principal meridians are hyperopic but one more so than the other, or both principal meridians are myopic, one more so than the other, the astigmia is compound. When one principal meridian is hyper- opic and the other myopic, the astigmia is mixed. 58 LESSONS ON THE EYE. The inequality of the refractive jxjwer of the principal meridians in an astigmic eye can only be equalized by the use of a lens which has different refractive power in its principal meridians. This requisite is found in the cylindric lens. A cylindric lens alone will correct simple astigmia; for compound and mixed astigmia a combination of cylindric and spheric lenses is necessary. ISOMETROPIA, ANISOMETROPIA AND ANTIMETROPI A. When the refractive condition of a pair of eyes is the same, or if there is any difference in them, it is too small to be detected by our present methods, they are said to be isometropic. If the refractive condition of the two eyes is the same in kind but different in degree they are said to be ani- sometropic. A slight difference in them is very com- mon and can hardly be considered a pathologic state. The term anisometropic is generally used when the difference is sufficient to impair vision or cause dis- turbance of the nervous system. If the refractive condition of the two eyes is different in kind they are said to be antimetropic. The term antimetropia does not refer to the degree of error, which may be equal or unequal. LESSON VIII. DISORDERS OF THE OCULAR MOVEMENTS. STRABISMUS. Normally both eyes fix the same object. The image of the object looked at falls upon the fovea centralis of both eyes. This is accomplished by the co-ordination and association of movement of the six external ocular Fovea Tovea Fig. 50. — The two eyes in a state of muscular equilibrium. The image of the candle A falls upon the fovea centralis of each eye. muscles of each eye. In looking up, down, right or left, the eyes move together and binocular or single vision results, because the images of objects in the field of vision fall upon identical parts of each retina, the upper half of the right retina corresponding to the upper half 59 6o LESSONS ON THE EYE. of the left, the right or temporal side of the right retina to the right or nasal side of the left, etc. In this normal state the eyes are said to be balanced or in equilibrium (Fig. 50). If this association of movement is disturbed, so that the image of an object falls upon the fovea centralis of one eye and not upon the fovea of the other, we have strabismus, or squint. The eye which receives the image of the object looked at upon its fovea is called the fixing eye; the other is called the squinting, or deviating eye. The deviation may be in any direction, depending upon which muscle or set of muscles is affected. Strabismus is either jmralytic or comitant. PARALYTIC STRABISMUS Is produced by loss of power in one or more of the oc- ular muscles. This loss of power may be total (paraly- sis) or partial (paresis) , the latter being by far the more frequent. When the paralysis is confined to those fibers of the third nerve which supply the iris and ciliary body the condition is known as internal ophthalmoplegia. When all the muscles of an eye are paralyzed except those of the iris and ciliary body the condition is known as external ophthalmoplegia. If both the internal and external ocular muscles are ])aralyzcd the condition is known as total ophthalmoplegia. Symptoms. — i. Movement of the eye in the direction of the action of the affected muscle is limited or lost. If an external rectus is ])aretic its antagonist, the inter- nal rectus, will pull the eye inward. The deviation of DISORDERS OF THE MOVEMEiNTS. 61 the afilicted eye, the sound eye fixing, is called the primary deviation. If the sound eye be covered by a card and the paretic eye fixes the object, it will be seen by looking behind the card that the sound eye has now deviated in a direction opposite to the i)rimary devia- tion, and that the deviation is greater. This is called the secondary deviation. In paralytic strabismus the fOVEA Fig. 51. — The eye is fixed on the candle. ()l)jccts in the right field ;il C are perceived by the left side of the retina at I). Objects at .A are perceived bv the right retina at B. secondary deviation is always greater than the primary, because the same amount of nervous impulse necessary to produce a given result in the weakened muscle is also conveyed to its sound associate and results in its overaction. 2. Diplopia or double \ision results because the muscular imbalance or lack of equilibrium prevents images of objects in the field of vision from falling upon the identical parts of each retina. The image of the 62 LESSONS ON THE EYE. fixing eye is called the true image; the image of the deviating eye the false image. If an external rectus is paralyzed the anterior pole turns in, the posterior pole out. The image of the object fixed by the sound eye falls upon the retina of the diseased eye, to the inner side of the fovea centralis and is projected to the temporal side of its field. This is due to the fact that Fig. 52. — Convergent strabismus of the right eye. The image of the candle A falls on the retina at the inner side of the fovea and is seen at B. Homonymous diplopia. A, true image. B, false image. the patient is in the habit of locating objects in the temporal field which are perceived by the nasal side of the retina (Fig. 51) and he does not take into con- sideration the deviation of his eye. If it is an internal rectus that is weakened the eye turns outward and the image of the object fixed by the sound eye falls on the retina of the diseased eye to the outer side of its fovea and is projected to the nasal side of the field. Thus it will be seen when the strabismus is con\-ergent DISORDERS Ol- THE MOVEMENTS. 63 the image of the right eye is on the right side, the image of the left eye on the left side. This is called homony- mous diplopia (Fig. 52). When the strabismus is divergent the image of the right eye is to the left, the image of the left eye to the right. This is called crossed or heteronymous diplopia Righl Fig. 53. — Divergent strabismus of the right eye. The image of the candle A falls on the retina at the outer side of the fovea and is seen at B. Heteronymous diplopia. A, true image. B, false image. (Fig. 53). In vertical strabismus the lower image belongs to the eye turned up, the upper image to the eye directed downward. 3. Inaccuracy in the determination of the position of objects in that part of the field toward which the affected muscle normally directs the eye is observed in paralytic strabismus. In looking toward an object on our right side, we determine by experience its distance to the right by the amount of innervation necessary to direct the visual axis toward it. If the right 64 LESSONS ON THE EYE. external rectus muscle is paretic, an unusual amount of energy is necessary to fix the object and it will seem farther toward the right side than it really is. 4. Vertigo, nausea and headache are troublesome features of paralytic strabismus. The \-ertigo is produced by diplopia and Ijy the inability to properly locate objects in ])art of the field of \-ision. 5. A peculiar carriage of the head will be observed. It will be turned in such a way as to overcome the diplopia by excluding the paretic muscle. If the right external rectus muscle is weakened the face will be turned toward the right side, which is ec[uivalent to directing the gaze to the left, in which act the paretic muscle would have to take no part. Cause. — The cause may be found in the Ijrain, the nerve-trunk, or in the muscle itself. If the lesion is in the brain it is said to be central; if in the ner\-e or its destribution it is peripheral. When the lesion is central there will probably be more than one muscle involved, other cerebral symptoms will be present and loss of power in the muscle or muscles will be gradual and progressive. When the lesion is peripheral the paralysis is generally limited to one muscle, there are no other symptoms and the loss of power is more complete. It is due to syphilis in about half of all cases and in the other half to exposure to cold, rheum- atism, diphtheria, tabes dorsalis, diabetes, poisons, tumors, meningitis, aneurism, periostitis, hemorrhage, wounds, fractures and hysteria. Treatment. — The subjective symj)toms can be relieved at once by covering the diseased eye. If the patient wears glasses, a ground glass (mi that side is effective. DISORDERS OF THE MOVEMENTS. 65 Treatment of paralytic strabismus must depend upon the cause. When due to syphiHs or rheumatism, the remedies appropriate to these conditions are indicated. When the result of debilitating causes, such as diph- theria, chronic poisoning, etc., give general tonics including strychnin. A weak current of electricity may be tried, the positive pole being placed over the affected muscle, the negative pole on the back of the neck. When the deviation is slight and has become fixed, relief is often afforded by wearing prisms. In selected cases operative treatment, tenotomy or advancement, may be helpful. LESSON IX. DISORDERS OF THE OCULAR MOVEMENTS {Continued) . COMITANT STRABISMUS. Symptoms. — There is an absence of the normal association of movement of the ocular muscles without loss of their power. The muscles have their normal Red, in L Fig. 54. — Scheme of the action of the ocular muscles. Q E, direction of traction of ext. recti; Qj, I, of int. recti; S i, of sup. and inf. recti; a, b, of inf. oblique; c d, of sup. oblicjue; (), point of rotation; (^ Qi, Transverse strength, but they do not work together so that each eye will fix the same object at the same lime. The relative direction of the visual axis is tlisturbed and though manifested by the de\'iation of one eye, the 66 DISORDERS OF 'JHE OCULAR MOVKMENTS. 67 motor apparatus of both eyes is inxohed. The primary and secondary deviations are equal The deviation may be monolateral or alternating; if the latter, vision in each eye will probably be the same. Internal comitant strabismus (esotropia) is a condition which usually manifests itself early in life, the average age being about three years. Divergent comitant strabismus (exotropia) usually manifests itself at about the age of puberty or a little later. The strabis- mus may be vertical ; the right or left eye may deviate upward (right or left hypertropia) . Diplopia is rare in comitant strabismus; the squinting eye is often so amblyopic as not to perceive the false image, and if it has good vision, comitant squint arises so early in life that there is developed, with the growth of the child, a power of the mind to exclude the false image. Cause. — There is more to discover relative to the cause of comitant strabismus than has yet been revealed, but the following may be given as etiological factors : I. Hyperopia exists in three-fourths of all cases of internal comitant strabismus. Convergence and ac- commodation are associated actions, and in hyperopia there is excessive accommodation and the associated convergence sometimes amounts to internal strabismus. Relief of the hyperopia by convex glasses will at times straighten these eyes. But that hyperopia is not a prime factor in the production of strabismus is proven by the fact that, in the majority of cases, the correction of the hyperopia by glasses has no effect on the strabis- mus, and also that there are so many cases of high degree of hyperopia in which there is no strabismus. 68 J,ESSONS ON THE EYE. 2. Myopia is associated with divergent strabismus and the explanation is that the convergence necessary to focus at the far point of a myopic eye, which is very close to the face, puts too great a strain on the internal rectus muscles, one of them gives up and divergence results. The exception to this rule is proven by the fact that only a very small proportion of the cases of myopia diverge. 3. Amblyopia or poor vision in the squinting eye is found in many cases of strabismus (72 per cent., Nagel) Fig. 55. — Large and small strabismus hooks. and the weight of authority is in fa\'or of the view that the amblyopia is congenital and is the cause of the strabismus, the stimulation to binocular vision not being present. However, a respectable minority claim the amblyopia to be the effect of non-use of the squint- ing eye and not the cause of the strabismus. But that congenital amblyopia is only a factor in the production of squint is proven by the absence of squint in the majority of amblyopic eyes. 4. Unusual development of a single ocular muscle is another possible element in the production of comitant strabismus, the internal rectus being often unnaturally strong in internal strabismus and the same is true of the external rectus when the deviation is outward , DISORDERS OF TI1['. OCULAR MOVF.MKNTS. 69 5. Defective development of the fusion faculty is suj)- posed to be a cause of strabismus. The faculty of fusing the images of the two eyes into one is a cerebral process developed early in life. Treatment. — Rarely comitant strabismus disaj)- pears without medical aid. Sometimes it is entireh- removed by wearing the glass which corrects the total refractive error, consequently these eyes should be tested and the proper glasses ordered as soon as the child is old enough to wear them. It is also good practice to cover the fixing eye with a bandage for a part of each day to compel the use of the deviating eye. Numerous exercises for the de\-elopment of the fusion faculty have been devised. Every method of this kind should be faithfully used before resorting to surgical interference. The treatment for the remaining cases is operative, tenotomy of the over-acti\'e muscle or advancement of its antagonist. Operations for strabismus should not be performed before seven or eight years of age, except in rare cases, owing to the tendency to development of over-effect with the growth of the child. INSUFFICIEXCY OF THE OCULAR MUSCLES, HETEROPHORIA OR LATENT SQUINT. This condition differs from strabismus only in degree, the tendency to deviation being overcome by the desire for binocular vision. It may be comitant or paretic. There is lack of balance of the ocular muscles l:)ut parallelism of the visual lines is maintained by an unconscious effort on the part of the patient. The 70 LESSONS ON THE EYE. effort to maintain this parallelism and secure binocular vision generally results in asthenopia, which may be manifested by pain over the insertion of the weak muscle, blurred vision, inability to do close or pro- tracted work, photophobia, subacute congestion of the conjunctiva, headache, vertigo and other neuroses. The following terms were introduced by Stevens to indicate the conditions present in latent squint: Orthophoria, perfect balance of the ocular muscles. Heterophoria, imperfect balance of the muscles or latent squint. Esophoria, a tendency inward or latent convergence. Fig. 56. — Strabometer. A simple but inaccurate instrunienl for measuring the amount of deviation in strabismus. Exophoria, a tendency outward or latent divergence. Hyperphoria, a tendency of the visual axis of one eye higher than the other. Jackson applies the term insufficiency of the ocular muscles to latent paralytic squint and limits Stevens' nomenclature to latent comitant squint. Cause. — The same as in manifest paralytic strabismus and manifest comitant strabismus. Diagnosis. — The cover test will reveal a latent squint of 2 or 3 degrees or more. Tt is made as follows: DISORDF.RS OF THK OCULAR MOVEMENTS. J I Ha\-c the patient fix one eye on an o!)ject at a distanee of 20 feet. Cover the other with a card. Binocular vision as well as diplopia are now impossible and therefore the influence which stimulates the patient to overcome this tendency toward deviation is no longer active. The muscle or muscles w'hich have recei\'ed the excess of innervation will relax and the covered eye will slowly assume the position in which the muscles are at rest. When the card is removed the covered eye will quickly return to the position of binocular fixation. The direction of this quick mo\-ement of the eye is opposite to the deviation and the amount of the devia- tion and recovery are equal. There are numerous instruments, found in every eye clinic, for the determination of the nature and amount of latent squint. It is not necessary, therefore, to describe them in this abbreviated text. Treatment. — The treatment of this condition is difficult and belongs to the oculist. Careful correction of any refractive error is of first importance. The constitution should be appropriately treated and use of the eyes regulated. In some cases wearing prisms gives relief. There are methods of exercising the weak muscle which may restore the necessary power. As a last resort operative measures may be adopted, which consist in tenotomy of the over-active muscle or advancement of the weak one. NYSTAGMUS. This condition is characterized by rapid, involuntary oscillation of the eyeballs, generally in the lateral direction. It may be congenital or ae(|uire(l and 72 LESSONS ON THE EYE. nearly always affects both eyes. If acquired, the patient will, at first, complain of the movement of objects looked at. Cause. — Defective development of the eyes, albinism, bad vision from corneal and lenticular opacities, blindness and protracted use of the eyes in an abnormal position, it being common with miners who work with their eyes directed obliquely upward. It is also due to l)rain lesions of central origin, ataxia and tumors of the cerebellum. Treatment. — Improve vision by all possible means; if there is any refractive error put on the correcting glass; if there is a central corneal scar make a false pupil. In case of strabismus do a tenotomy or advancement, and if the occupation is at fault change it at once. The great majority of cases of nystagmus get little or no relief. LESSON X. DISEASES OF THE LIDS. bl?:pharitis. This is an inflammation of the lid border character- ized by the following symptoms given in the order of their severity, i. Hyperemia, itching and slight swell- ing. 2. Seborrhea or hypersecretion of the sebaceous glands. The dried sebum forms yellaw crusts on the border of the lid. 3. Ulceration at the root of the lashes. 4. Thickening of the edge of the lid. 5. Falling of eyelashes with atrophy of their follicles. 6. Ectropion with eversion of the lacrymal puncta and resulting epiphora. -Blepharitis, eyelashes matted into bundles h}- the secretion alonf]; lid borders. Cause. — It is sometimes eczematous in nature and is most frequently found in the fair-skinned, the strumous and the badly nourished. Chronic conjunctivitis, lacrymal obstruction, errors of refraction, exposure and abuse of eyes are causative. It frecjuently follows the exanthematous fevers. The disease is limited to no age but is most frequent in children. 73 74 LESSONS ON THE EYE. Treatment. — Correct the refractive error. Protect eyes from the irritation of dust, smoke, etc. Treat the constitution with cod hver oil, iron and arsenic if struma or debihty are present. If there are ulcers around the cilia pull out the lashes so affected and touch the ulcers with nitrate of silver stick. Rub into the edge of lids, once a day, an ointment of the yellow oxid of mercury, gr. h to vaseline 5i, or an ointment of ammoniatcd mercury, gr. h to oi- Before applying the ointment all secretion should be cleansed from the lid border. Eight grains of biborate of soda to one ounce of warm water will be found useful in removing the crusts. If there is lacrymal obstruction it must receive appropriate attention. In the chronic stage of blepharitis stimulating tar ointments are recommended but in the majority of cases mild and soothing measures will be the most efficacious. HORDEOLUM. A stye is an acute inflammation of a sebaceous gland at the lid border. It is usually, in appearance and symptoms, a small boil, but sometimes produces general edema of the lid with chemosis of the con- junctiva. Cause. — Error of refraction, general del)ility, con- stipation, and germ infection. Treatment. — Use hot applications to bring the inflammation to a focus, then ojx'n. Correct the constitutional condition if debility exists. Correct refractive errors and remo\'e any source of local irritation. vSulfid of calcium, \ grain twice a day or DISEASES OF THE LIDS. 75 dilute sulfuric acid ten drops after each meal may be given. A stye can sometimes he alnjrted in the earliest stages by the use of cold a])])lications. CHALAZION. This .small tumor of the lid is due to a chronic inflam- mation of a Meibomian gland. Hala claims this Fig. 58. — Chalazion of upper lid. iniiammation to be the product of the xerosis bacillus. Its development is gradual and usually without any symptoms which annoy the patient. The inflam- matory process causes proliferation of the epithelial lining of the gland and cell infiltration of the surround- ing tissue. This inflamed area develops into a granu- lation mass surrounded by a thin connective tissue capsule. The granuloma tends to break down in the center, forming a liquid, which may become jnu-ulent. Rarely the mass becomes fibrous and solid. 76 LESSONS ON THE EYE. Treatment. — The contents may escape and the tumor disapj^ar spontaneously. Sometimes they can be cured by hot apphcations, massage and ammoni- ated mercury ointment. An operation is generally necessary. The incision may be made through the skin or conjunctiva, depending upon the proximity of the Fig. 5q. — A, method of applying lid forceps for removal of i halazion throuj: the conjunctiva; B, lid forceps. tumor to these surfaces. If the incision is in the skin it should be made parallel with the lid border so as not to divide unnecessarily the fibers of the orbicularis muscle. If the incision is made through the con- junctiva it should be vertical to the lid border to avoid cutting the ducts of the Meibomian glands. If the tumor is soft enough a curette will remove it. Some- times, to accomplish a thorough removal, it has to be dissected out. DISEASES OF THE LIDS. 77 TRICHIASIS. W'iKl hairs, misplaced or misdirected eyelashes rubbing, the globe, produce great pain and blepharo- spasm and may cause ulceration and subsequent opacity of the cornea. Cause. — If the trichiasis is partial it may be con- genital or may be due to the cicatricial contraction following styes, blepharitis ulcerosa, traumatism, etc. If there is a complete trichiasis it is usually associated with entro])ion and is, as a rule, the result of trachoma. Fig. ()o. — Trichiasis of upjier lid. Treatment. — i. Epilation or pulling out of the offending hairs is only of temporary benefit, as they grow in again. 2. Electrolysis, introduced by Michel of St. Louis, is valuable. A needle attached to the negative pole is passed to the hair bulb, which is killed by a current of about five milliamperes. This procedure is exceedingly painful. 3. Excision of the misplaced hairs with their bulbs is useful when they are few in number and close together. 4. If the wild hairs are isolated their direction can be changed by passing a needle, threaded with a loop, through the lid in the 78 LESSONS ON THE EYE. direction you wish the hair to take, then catching the hair in the looj) and drawing it through the tissues as you puh the thread through. 5. When the trichiasis is total and the hd border is turned inward, one of the operations for entropion should be done. ENTROPION AND ECTROPION. Entropion is a turning in of the lid. Ectropion is a turning out of the lid. I. We have spasmodic entropion and spasmodic ectropion. Spasmodic contraction of the fibers of the orbicularis near the lid border in conjunction with a relaxed and Fig. 61. — Entropion of the lower lid. (.\fter Mackenzie.) flabby skin and a deep-set eyeball causes the lid border to turn inward, producing spasmodic entropion, which is nearly always found in the aged. This condition occurs almost without exception in the lower lid. Spasmodic contraction of the fibers of the orbicularis farthest from the lid border, in conjunction with a tense skin, congested and thickened conjunctiva or a promi- nent eyeball, cau.ses the lid border to turn outward DISKASKS OF THE LIDS. 79 producing spasmodic ectropion, which is nccui)' ah\'ays found in children and young people. 2. We have cicatricial entropion and cicatricial ectropion. Trachoma', some forms of conjunctivitis and wounds may produce cicatricial contraction of the conjunctiva lining the lid which turns the edge of the lid inward, causing entropion. Fig 62 — Ectropion ot lower lid Burns, wounds, ulcers, caries of the orbital border and other causes may produce cicatricial contraction of the skin of the lid, which turns the edge of the lid outward, causing ectropion. We have, in addition to the above conditions, a paralytic ectroj^ion due to paralysis of the orbicularis muscle. The lower lid falls outward and away from the globe by its own weight. The lower lid is the only one affected by paralytic ectropion. The treatment is almost always o])erative. Spas- modic entropion can be temporarily relie\-ed by paint- ing the skin over the inferior orbital margin with collodium, contraction of which everts the lid border. 8o LESSONS ON THE EYE. ANKYLOBLEPHARON. The edges of the upper and lower hd may grow to- gether producing a condition called ankyloblepharon. It may be congenital or acquired; partial or complete. Fig. 63. — Ankyloblepharon. The cause is some accident or disease which leaves the lid margins in a denuded and granulating state. If in this condition the raw surfaces are kept in apposition they will grow together. LESSON XI. DISEASES OF THE LIDS (Continited). BLEPHAROSPASM. Spasm of the orbicularis appears under a variety of forms: i. Abnormal frequency of winking or nictita- tion may be an unconscious habit which sometimes lasts a life-time. 2. A similar manifestation is seen in children, due to chronic conjunctivitis, V)ut it may be the beginning of a general chorea. 3 . In hysteria there is sometimes pronounced blepharospasm, which may be tonic or clonic. 4. In old age a tonic blepharo- spasm, which resists all treatment, may occur (Fuchs). 5. A reflex spasm of the orbicularis may be due to trichiasis, corneal and conjunctival diseases, foreign bodies, errors of refraction, and to any condition which can cause photophobia. Treatment is to remove the cause. 6. There is a clonic form of blepharospasm corresponding with tic douloureux, which is very pain- ful. At gi\'en intervals the cramp seizes the orbicularis and other muscles of one side of the face, causing dis- tortion and great pain. The paroxysm passes off in about a minute, to be repeated again after an interval varying in length in different cases. An average of four to six attacks an hour have been observed. The cause is some nerve or brain lesion, and treatment is very ineffectual. lodid and bromid of potassium have each been beneficial. If any peripheral, exciting cause can be discovered, it should be removed. 6 81 82 LESSONS ON THE EYE. LAGOPHTHALMIA. Lagophthalmia is an inability to close the lids. Con- stant exposure of the globe causes conjunctivitis, ulceration of the cornea, and an overflow of tears, due to the malposition of the punctum. The evils of lagophthalmia are lessened by the tendency of the cornea to turn upward under the lid when an effort to close the palpebral fissure is made. This also occurs in sleep. Cause. — I. Protrusion of the eyeball as in exophthal- mic goitre or orbital tumors. 2. Large anterior staphy- loma. 3. Congenital shortening of the lids. 4. Loss of lid tissue from lupus, burns, etc. 5. Ectropion. 6. Paralysis of the seventh nerve. The course of this nerve is long and devious, and it passes through numer- ous tissues, which exposes it to accident or disease. Treatment. — The treatment consists in removing the cause, meanwhile protecting the cornea from irritation by covering the eye with a bandage or holding the lids together with adhesive plaster. In the erect position, the force of gravity will help to draw the lid down o\-er the cornea. In some cases tarsorrhaphy is necessary. This consists in shortening the palpebral fissure by uniting the edges of the lids. PTOSIS. Ptosis is a complete or partial drooping of the upper lid. Vision may be obstructed by the lids covering the ]3upils. To prevent this the patient throws his head backward and tries to raise the lids by elevating the brows. If congenital it is frequently bilateral; when acquired it is generally unilateral. DISEASES OF THE LIDS. 83 Caitsc- -The causes of congenital j^tusis are: 1. De- ficient development or absence of the levator palpe- brcB superioris muscle. 2. Injury inflicted by the forceps in difficult delivery. 3. Defective attachment of the skin to the underlying tissues, ]:>roducing that Fig. 64. — Acquired ptosis of syphilitic origin. The effort to raise the lids by elevating the eyebrows is shown. form called ptosis adiposa, in which the skin falls over the lid border like a pouch. The causes of acquired ptosis are : 1 . Injury to the levator muscle. 2. Paralysis of the third nerve, usually from syphilis (Fig. 64). 3. Thickening of the lids by new growths, trachoma, etc. 4. Hysteria. 84 LESSOiNS ON THE EYE. Treatment. — Attack the cause when it can be located. The congenital forms require operations. In paralysis use anti-syphilitic and anti-rheumatic measures. Elec- tricity, one pole back of the ear and the other over the lid, mav be tried. ECZEMA. Eczema of the lids is most frequently met with in children who have phlyctenular ophthalmia, and in adults with an irritating discharge from the eye. The symptoms and treatment are the same as of eczema in other parts. In an acute case treatment should be mild and soothing ; when chronic it can be more stimu- lating. Dust with starch powder or aristol. Apply oxid of zinc ointment to which carbolic acid, 5 grains to the ounce, may be added*. Yellow oxid of mercury ointment is useful, as is also painting with nitrate of silver solution, 10 to 20 grains to the ounce. HERPES ZOSTER OPHTHALMICUS. This term is applied to shingles following the course of the first and second divisions of the fifth nerve. It is characterized by redness and swelling of the skin and the formation of vesicles on the forehead, eyelids and nose. The disease is very painful and is a menace to sight if the vesicular eruption appears on the cornea. A severe neuralgia generally precedes the attack and may persist for a long time after it. The cause of the disease is an inflammation of the fifth nerve of an ob- scure character. Treatment is unsatisfactory. The DISEASES OF THE I.TDS. 85 Vesicles should not be ruptured and when they dry form- ing crusts, the latter should remain undisturbed. Pick- ing off the crusts deepens the subsequent scars. Ano- dynes may be required. Internally salicylic acid and quinin have both l)een recommended. Fig. 65.— Clamp used lo prevent hemorrliage and steady the part in lid operations. PHTHIRIASIS. Crab lice may get into the eyelashes and give rise to excessive itching ; the consequent rubbing and scratch- ing of. the lids sets up a mild inflammation which may be mistaken for blepharitis. The hce and their eggs may be seen on the cilia. Treatment is to rub the lid border and lashes thoroughly with mercurial ointment every night until the parasites are killed. ECCHYMOSIS OF THE LIDS. A "black eye" is the result of any cause which rup- tures a blood vessel of the subcutaneous tissue of the lid. It is most frequently due to a blow^ Time is the only cure. A bandage, cold applications immedi- ately after the accident, arnica or lead and opium wash will assist. When all subcutaneous oozing has ceased and the clot is formed its absorption may be hastened by hot applications and gentle massage. 86 LESSONS ON raE EYE. Epithelioma or rodent ulcer of the lids is not a rare disease in elderly people. Its site of election is at the margin near the inner canthus and usually on the lower lid. It develops slowly. The absence of other evi- dences of syphilis will assist in differentiating it from a syphilitic ulcer. It can be distinguished from lupus by the fact that lupus begins much earlier in life and ex- tends to the lids from its starting point on some other part of the face. Excision, caustics and cautery are the methods advised for its removal. The tendency to recurrence at times renders all these methods useless. The X-ray has been found curative in these cases and should be tried. Sarcoma of the lids is rare. Lupus, molluscum contagiosum, xanthelasma, milium and nevus are diseases of the skin of the lids whose description be- longs more properly to a work on skin diseases. Ery- sipelas may attack the lids, and if it extends to the orbital tissues there is some danger of serious conse- quences, such as orbital abscess, optic neuritis, optic atrophy, thrombosis of the retinal vessels, and throm- bosis of the intra-cranial venous sinuses. The primary syphilitic sore has been known to appear upon the lids. The various eruptions of secondary syphilis and tertiary ulceration are more common. Syphilitic ulceration must not be mistaken for lupus or epithelioma. LESSON XII. DISEASES OF THE LACRYMAL APPARATUS. EPIPHORA. The lacrymal system is divided into a secretory part, the glands, and an excretory or drainage part, the puncta, canaUcuH, sac and duct. Normally the lacry- inal secretion is about balanced by evaporation. When the tears overflow on to the cheek the condition is called epiphora. It is the most constant and significant Fig. 66. — Fistula of lacrymal sac symptom of disease of the lacrymal apparatus. There are two forms of epiphora; one related to the secre- tion and the other to the drainage of tears. I. Epiphora caused by excessive secretion may be due to the influence of certain emotions such as grief or laughter; acute disease particularly of the cornea and iris; chronic conjunctivitis and irritation of the 87 88 LESSONS ON thp: eye. conjunctiva by foreign l)odies, wind, dust or smoke; irritation of the retina by bright hght; irritation or disease of the mucous membrane of the nose; and neuralgia of the fifth ner\-e. This form is called reflex epiphora. 2. Epiphora caused by impairment of the drainage apparatus may be due to eversion or occlusion of the puncta, plugging or stricture of the canahculi, inflam- mation of the sac or stricture of the duct. The amount of epiphora resulting from defective drainage alone is either not appreciable or very slight as evaporation will about dispose of the normal secretion. It would follow, then, that obstruction of the drainage apparatus must be associated with some condition productive of hypersecretion of tears in order to cause epiphora. A moderate hypersecretion of tears will not cause epiphora if the drainage apparatus is patulous, as the fluid will be carried into the nose, but with the drainage obstructed the smallest excess of tears must overflow the hds. DISEASES OF THE LACRYMAL GLAND. I. Inflammation of the lacrymal gland occurs very rarely. It may be acute or chronic. There would be the usual symptoms of inflammation which might result in suppuration or recover without it. There is often difficulty in excluding orbital celluHtis, phlegmon of the lid and periostitis, owing to the pronounced chemosis of the conjunctiva and great swelling and tenderness of the parts. Treatment consists of hot bichlorid fomentation, anodynes and evacuation of the pus if formed . DISEASES OF THE J.ACRYMAL APPAR.\TUS. 89 2. Dislocation of the latTymal sj;land appears as a movable tumor under the ocular conjunctiva at the upper and outer part of the globe. Treatment does not avail. Extirpation may be resorted to. 3. Tumors of numerous varieties may develop in the lacrymal gland. Hypertrophy and atrophy have been observed. A tumor or hypertrophy of the gland would tend to force the eyeball downward and inward, caus- ing diplopia. If the growth developed behind the ball exophthalmos would follow. Extirpation of the diseased gland is the only measure likely to prove beneficial. 4. Fistula of the gland is generally the result of an abscess or injury. A connection w4th the conjunctival sac should be established, then the cutaneous opening is easily closed by cauterization. 5. Dacryops is the term applied to a bluish, trans- lucent, soft tumor which appears in the upper and outer conjunctival fornix. It is caused by the occlusion of one or more of the ducts which convey the lacrymal fluid from the gland into the conjunctival sac. As the tumor is a distended duct filled with tears it will collapse if punctured and the treatment consists in establishing a permanent opening. ANOMALIES OF THE PUNCTA AND CAXALICULI. I. Eversion, or falling ui the lower punctum away from the eyeball, may be due to ectropion, chronic con- junctivitis, blepharitis marginalis, lagophthalmia, or the relaxation of the lower lid found in old age. Though the upper punctum may be in its normal posi- tion, epiphora will follow any hypersecretion of tears. 90 LESSONS ON THE EYE. 2. Obliteration of a punctum or canaliculus may be congenital or mav result from traumatism or chronic inflammation. 3. Obstruction of a canaliculus by a foreign body sometimes occurs. Fig. 67. — Weber's straight canaliculus knife. CHRONIC DACRYOCYSTITIS. This is a catarrhal inflammation of the sac and duct. Stricture of the duct will also be included under this head as these conditions merge into each other and are more or less interdependent. Symptoms. — A slight catarrhal inflammation of the mucous membrane of the sac and duct creates a muco- purulent discharge, some of which passes backward through the puncta and produces a mild conjunctivitis and epiphora. This slight attack may disappear with- out treatment, or upon the instillation of some mild antiseptic collyrium and the appropriate attention to the nose. If the inflammation is more severe, the swell- ing of the mucous membrane will produce an occlusion of the duct and a consequent accumulation of the con- tents of the sac. The muco-purulent contents will be- come purulent, and will escape through the puncta and excite a conjunctivitis. With this conjunctivitis there will be hypersecretion of tears and epiphora. The ac- cumulation of fluid in the sac produces a tumefaction which will disappear upon pressure, as the fluid is forced back through the puncta or through the stricture into the nose. The stenosis of the duct may be complete. DISEASES OF THK LACRYMAL APPARATUS. 91 The purulent contents of the cHstended sac arc ex- tremely toxic and will almost surely infect a wound of the cornea, will often light up an active inflammation of the connective tissue surrounding the sac (acute da- cryocystitis), and may, if of long standing, i)ro(luce caries of adjacent bone. Fig. 68. — Slitting the canaliculu.s. Cause. — Dacryocystitis may be started by any of the numerous causes of inflammation of mucous membrane, such as temperature changes and infection. Stricture of the duct will cause a dacryocystitis, and stricture may be due to morbid conditions of the nasal cavities, traumatism, asymmetry of the face, deflected septum, periostitis or syphilis. The prognosis in chronic cases Q2 LESSONS ON THE EYE. is bad. If cured they require months of treatment, and too often patients have not time or inclination to resort to the needed measures. Treatment. — Teach patients to keep the sac empty by pressure. Have the nose examined and. treated if any morbid condition is found. Appropriate attention must be given to any constitutional condition, such as syphiHs or struma, which may be present. The mildest form is sometimes benefited by dropping into Fig. 69.— Bowman's jMohes for dilating the nasal diut. the eye, three times a day, a i to 2,000 solution of blue pyoktanin, or a weak sulfate of zinc or alum solution. Wash out the sac with a i to 10,000 solution of bichlorid of mercury, or a w^arm boracic acid solution, every other day. If the discharge is purulent, inject into the sac a small quantity of a solution of nitrate of silver (gr. 2 to the ounce), protargol (5 to 20 per cent.), or argyrol (10 per cent.), after having cleaned it out by washing with bichlorid of mercury or boracic acid solutions. If there is a stricture of the duct probing may be necessary. If a canaliculus must be slit in (^rder to probe, sHt the upper. These two procedures, though simi)lc, would better DISKASKS (J|- IHK LACRYIVLAL APPARATUS. 93 be learned clinically. Great care must be observed in probing, as there is danger of lacerating the tissues around the sac. This is particularly true of the early stages of treatment when small probes are being used. A preliminary injection of cocain into the sac will render the operation less painful. The use of extract of the supra-renal gland, by reducing the vascularity of the mucous membrane of the duct seems to facilitate the passage of probes. When the probe is removed the sac and duct should be treated with an injection of one of the antiseptics or silver preparations al)ove mentioned. How often to probe, how long to leave the probe in the duct, and the maximum size of the probe to be used are questions upon which various opinions 94 LESSONS ON THE EYE. are entertained. The author fa\'ors small probes and as little use of them as possible. Obstruction of the lacrymal drainage is often ob- served in the new-born. A weak zinc or silver solu- FlG. 71. — Syringe for injecting the lacrymal jjassages. tion will generally effect a cure. Surgical interference should be postponed until all milder methods have failed. ACUTE DACRYOCYSTITIS. Symptoms. — In the course of a chronic dacryocystitis, a severe inflammation may suddenly dex'clop in the DISEASKS OF THK I.ACRVMAL AFI'ARAIUS. 95 region of the sac. There will l)e redness and swelling which will extend to the lids and conjunctiva. Pain will be very severe and there mav be some fever. Pus will form and the skin oxer the ab.scess become thin. Unless opened the skin will break, emptying the con- tents of the abscess and establishing a lacrymal fistula Fig. 72. — .\cute dacryocystitis. (Fig. 66). As soon as the pus is evacuated the symp- toms rapidly subside to recur as soon as the fistula is allowed to close. Cause. — A lesion of the mucous membrane of a sac affected by chronic dacryocystitis, allows its toxic con- tents to infect the surrounding sub-mucous tissue and the active phlegmonous inflammation follows. Treatment. — Evacuate the pus by slitting up a canahculus if possible, if not open through the skin over g6 LESSONS ON THE EYE. the sac. Cleanse with some antiseptic solution and if the swelling and pain are considerable use hot, antiseptic compresses. Keep the incision open by gauze drain- age until the abscess can be cleansed through a canal- iculus and then treat as a chronic dacryocystitis. In obstinate cases of dacryocystitis it is sometimes deemed expedient to completely obliterate the drainage passages. For example, a cataract operation should never be attempted in the presence of a discharge from the lacrymal sac, owing to the imminent danger of infecting the corneal wound. The sac may have to be obliterated to stop the discharge. This is done by dissecting it out or destroying it with the actual or chemical cautery. LESSON XIII. DISEASES OF THE OF^BITS. MENINGOCELE. Sometimes there is defective dexelopment of the bones of the orbital rim where the nasal wall and roof of the orbit unite. The result is a congenital, cystic tumor in this region, composed of the meninges of the brain, filled with cerebral fluid. The tumor is called a meningocele, or if it contain brain substance, an en- cephalocele. It may be mistaken for an ethmoidal muco- cele, sebaceous cyst or dermoid tumor. The following diagnostic points should be remembered : 1. It is congenital. 2. It gives the impression of being firmly attached to the bone. 3. There is a pulsation of the cerebral fluid in a meningocele synchronous with the heart beat. 4. Steady pressure will force some of the contents of a meningocele back into the cerebral cavity and then the opening in the bony wall may be felt with the point of the finger. 5. Symptoms of increased cerebral pressure may be excited when the fluid is forced back into the cerebrum. A meningocele should not be disturbed. PERIOSTITIS. Periostitis may attack any part of the orbit l)ut is most frequent at the margin. When superficial the 7 97 ge> LESSONS on the eye, hard swelling and tenderness upon pressure make the diagnosis simpler than when deep in the orbit. The latter form is often hard to differentiate from orbital cellulitis until a fistula is formed and rough bone can be detected with a probe. Symptoms. — Before entering upon the symptomat- ology of the few inflammatory conditions to which the orbit is subject, it is well to mention that there are a number of symptoms common to nearly all diseases of the orbits. Of these there are two so constantly in attendance as to make them worthy of special mention. 1. Proptosis or exophthalmos. 2. Limitation of movement of the eyeball. Associated with these salient symptoms are diplopia, injection and chemosis of the conjunctiva, redness, swelling and edema of the lids and severe pain, most noticeable when the patient attempts to move the globe, or the surgeon presses it backward into the orbit. The character of the symptoms in periostitis will depend upon whether the inflammation is checked in the stage of periosteal thickening or goes on to suppura- tion. Also whether acute or chronic, circumscribed or diffuse, external or deep-seated. When external all the signs of local inflammation will be present. Unless checked in the first stages, pus will form under the skin and when discharged a sinus will be established through which rough bone can be de- tected. The discharge keeps up for a variable period and when the fistula is healed it leaves the characteristic funnel-shaped dimple in the skin, which is adherent to the underlying bone. If there is much contraction of the skin ectropion results. DISEASES OF THE ORBITS. QQ When deep-seated and non-suppuratixe, the symp- toms will be pain and probably protrusion of the ball with some limitation of its movement. When suppu- ration takes place the sym])toms are j^ractically those of orbital cellulitis, page loi. Caries and necrosis mav result. Periostitis of the roof of the orbit is the kind most likely to cause meningitis, owing to the thinness of the bone here and the proximity of the brain. Cause. — Injury, syphilis, scrofula and rheumatism. When syphihtic it is usually a tertiary manifestation. Treatment. — The constitutional treatment appro- priate to the cause should be instituted. Locally apply hot compresses, evacuate pus when formed, establish drainage and wash out antiseptically. Correction of any resulting deformity such as ectropion or lagophthalmia should not be attempted until the periostitis is entirely well. CARIES AND NECROSIS. Caries and necrosis occur most frequently at the margin of the orbit, owing to its greater exposure to injury. They generally begin as a periostitis. The course of the disease is chronic, sometimes covering a period of several years. A bad scar is the usual result, the skin contracting and adhering firmly to the under- lying bone. The danger of meningitis is greatest when the horizontal plate of the frontal bone is the part involved. The treatment consists in establishing good drainage and cleansing frequently with antiseptic injections. lOO LESSONS ON THE EYE. HYPEROSTOSIS, PERIOSTOSIS AND EXOSTOSIS. Hyperostosis (thickening of bone) , periostosis (thick- ening of the periosteum), and exostosis (new bone developed from the periosteum) , may occur in the orbit. The symptoms will depend upon the extent and loca- tion of the process. If of any size exopthalmia will be noticed. If located near the sinuses at the apex, the circulation in the orbit may be interfered with or pressure may be exercised upon the optic nerve or nerves supplying the ocular muscles. The treatment consists of alteratives internally or surgical removal. INJURIES OF THE ORBIT. Fractures may be marginal or deep-seated. Deep- seated fractures may be the result of force applied directly or indirectly. There will be hemorrhage into the orbit with protrusion of the ball. If the inner wall is fractured blood will escape through the nose and air may be forced into the cellular tissue of the orbit and lids producing emphysema. Direct fractures of the roof, for example, from a knife or cane are exceed- ingly dangerous to Hfe, owing to the injury to the brain which is almost inevitable. Fractures extending into the optic foramen are dangerous to \-ision, owing to direct injury to the nerve or hemorrhage into its sheath. The contents of the orbit are subject to all kinds of injuries. Many remarkable cases have been reported, showing the great tolerance of the orbital tissues to the presence of foreign bodies. The following, reported by Carter, will suffice. A man fell down a flight of steps, at the bottom of which was a row of hat pegs. DISEASES OF THE ORBITS. lOI He cut his eye lid, but did not consult a surgeon for a few days. The surgeon had treated him several days before noticing a foreign body in the wound. It proved to be the shaft of a hat peg 3^ inches long. The X-ray is of great value in determining the presence and location of foreign bodies in the orbit. The treatment of all orbital injuries should be based upon established surgical principles. In the use of antiseptics, however, the sensitiveriess and delicacy of the conjunctiva and cornea must not be overlooked. ORBITAL CELLULITIS. This is an inflammation of the cellular tissue of the orbit which may be acute or chronic, but usually results in suppuration with the formation of an abscess. Symptoms. — Proptosis with diplopia, pain, limitation of movement of the ball, injection and chemosis of the conjunctiva and sweUing and redness of the lids. As the severity of this disease varies greatly in different cases, we shall expect variation in the degree of mani- festations of all symptoms. In the severe forms there will be chills with fever, and may be loss of vision due to pressure upon the optic nerve or disturbance of the intra-ocular circulation. There may be ulceration of the cornea and possibly suppuration of the whole eyeball. Thrombosis of the intra-cranial venous si- nuses and meningitis ha\-e both resulted from orbital suppuration. Cause. — The causes are such as produce cellulitis in other locations and are numerous. They may be traumatic or idiopathic. Special mention may be flOO E. Clinton /ky%, I02 LESSONS ON THE EYE. made of the severe form due to erysipelas, and also to the fact that it may arise by metastasis in all pyemic conditions, or puerperal septicemia. It may follow thrombosis of the ophthalmic vein and has been known to result from abscesses of the teeth in the upper jaw. Suppuration in the adjoining cavities (frontal sinus, ethmoid cells and sphenoidal sinus), may extend to the orbit. Fig. 73. — Double orbital cellulitis, the result of erysipelas. (De Sihweinitz Treatment. — Support with tonics, especially quinin and iron. Relieve pain by anodynes. Apply hot fomentation, and as soon as the abscess can be located or any sign of fluctuation appears, open and treat antiseptically. When the exophthalmos is very pro- nounced and the pain intense it is advised to make an incision into the orbit, through the conjunctiva without waiting for evidence of suppuration. In making the DISEASES OF THE ORBITS. IO3 incision the flat side of the knife sliould be (hreeled toward the ball and the ocular muscles avoided. Inflammation of the capsule of Tenon has been known to occur without involving the cellular tissues of the orbit. When idiopathic it is generally rheumatic in origin and the treatment should be directed to that dyscrasia. The traumatic form has often been caused by infection following an operation upon the muscles for the correction of strabismus. The treatment is the same as in orbital cellulitis. TUMORS OF THE ORBIT. The orbit contains many different tissues, con- sequently a great variety of tumors may develop in this locality. Those which originate in adjoining cavities may reach a large size before any symptoms of orbital disease become manifest. It is therefore well to determine, if possible, whether other cavities are involved. When there is an exophthalmos, which has developed slowly, combined with limitation of movement, without the usual manifestations of inflam- mation, the diagnosis of a tumor may be arrived at with a degree of assurance. If, however, the tumor has developed rapidly and is associated with symptoms of active inflammation, the differentiation from ]X'ri- ostitis, orbital cellulitis, etc., may be difficult. If the nature and extent of the growth will admit, it should be removed without the ball. To accomplish this it may be necessary to temporarily resect a wedge- shaped piece of the outer orbital wall. When the tumor is malignant the most radical removal of eye- I04 LESSONS ON THE EYE. l)all and orbital contents secures no immunity from a probable recurrence. PULSATING EXOPHTHALMOS. This condition may develop slowly but its onset is usually sudden. The patient may be conscious of a rupture or giving way of some structure in the head. This sensation is soon followed by protrusion of the ball, congestion of the conjunctiva, swelling of" the lid, pain, pulsation of the eyeball, and a bruit heard over the orbital region. If firm pressure is applied over the eye it can be forced back into its normal position. When back the bruit may no longer be heard and the roaring sound, so annoying to the patient, generally ceases. Sometimes vision is much impaired and the ophthalmoscope shows a swelling of the optic disc with distortion and enlargement of the retinal veins. Cause. — It is generally due to rupture of the internal carotid artery within the cavernous sinus. It may be traumatic or spontaneous. If the latter there must ha\'e been a diseased condition of the artery which thinned its walls. Aneurism of the ophthalmic artery is sometimes the cause. Treatment. — The object of treatment is" to establish a clot in the ruptured artery. Compression of the common carotid should be tried. Digital or instru- mental pressure should be exerted, for as much of the time of each day as the patient can endure it. If this fail, ligation of the common carotid must be resorted to. If the patient escapes the dangers incident to this operation the pulsating exophthalmos will usually be found cured. LESSON XIV. DISEASES OF THE C(3NJUNCTI VA. CATARRHAL CONJUNCTIVITIS. This is the most frequent disease of the eye. It usually attacks both eyes, varies greatly in severity and duration, and lends to spontaneous recoverv, I'"iG. 74. — Conjunclival congestion. The circumcorneal zone the last jiart to become injected. rarely lasting o\'er two weeks. Hyperemia of the con- junctiva is generally given as a separate disease, but practically differs from simple catarrhal conjunctivitis only in degree, being milder. 105 I06 LESSONS ON THK EYK. Sy)upto)us. — 1. Congestion of the palpebral and ocular conjunctiva, the pericorneal zone remaining normal or the last part to become red. (Fig. 74.) 2. Pain of a scratchy, burning kind, feeling often as if there was a foreign body under the Hds. 3. Vision slightly diminished owing to the presence of mucus and pus on the cornea. 4. Discharge of a muco-purulent nature which mats the lashes into small bundles and sticks the lids to- gether during sleep. 5. Photophobia or intolerance of light. 6. Swelling of the lids (slight) and some thickening of the conjunctiva. Cause. — Foul atmosphere, dust, smoke, wind, heat, cold, the glare of the sun, and errors of refraction. The exanthematous fevers, diseases of the lacrymal sac and duct, nasal catarrh and hay fever. A very contagious form of catarrhal conjunctivitis, w^hich at times becomes epidemic, is caused by a small bacillus described by Weeks, and a conjunctivitis clinically very similar to that produced by the Weeks bacillus is due to the pneumococcus. Also a mild but per- sistent form of catarrhal conjunctivitis is associated with the presence of the diplo-bacillus of Morax and Axenfeld. Treatment. — Remove the cause if discovered. Rest eyes and keep them clean. Use a cold compress as follows : Acidi borici 5^ Tinctura: opii deodorat^c 3vi Aqme destellatiu, (]. s. ft. . . . o\'^^i DISEASES OF THE CONJUNCTIVA. I07 This is to be applied to the outside of the closed lids, on a thin cloth, folded once or twice, for fifteen minutes at a time, four times a day. The solution should be ice cold when used and the wet cloths changed every minute. Apply a weak yellow oxid of mercury oint- ment or boric acid salve to the edge of the lids at night to prevent adhesion. If discharge is profuse or ])uru- lent, paint everted lids, once a day, with a solution ot nitrate of silver, one to two grains to the ounce, or a 2 to 5 per cent, solution of protargol. One drop of a 10 per cent, solution of argyrol, three or four times a day, is often very beneficial. Argyrol is painless and practically non-irritating. A fresh solution should be used. Astringent collyria containing sulfate of zinc, tannin, alum, etc., are very popular. They are capable of mischief if, through an error of diagnosis, they are used in iritis, cyclitis or acute keratitis. An exception should be made of the diplo-bacillus conjunctivitis, in which form zinc acts as a specific. CHRONIC CATARRHAL CONJUNCTIVITIS. Symptoms. — After the subsidence of an acute attack the same general symptoms may persist in a milder form or they may develop slowly without an acute manifest- ation. In the chronic form the palpebral conjuncti\-a and the fornix are the parts chiefly involved. Cause. — The same agents which produce acute catarrhal conjunctivitis, but especially those which are slow and continuous in their action. Treatment. — The source of any chronic irritation should be removed and the same line of treatment Io8 LESSONS ON THE EYE. as recommended for an acute attack instituted. Stronger remedies are more applicable to the chronic form, and zinc, alum, argyrol, nitrate of silver, protar- gol or sulfate of copper may be used. Caution shotild be observed in the continuous use of the silver prepa- ration sowing to the danger of producing a dark, muddy discoloration of the conjunctiva called argyria. PURULENT CONJUNCTIVITIS. This condition may be divided into two forms: i. The infantile variety or Ophthalmia Neonatorum, which arises between the third and eighth day after birth Fig. 73. — Purulent conjunctivitis. and generally attacks both eyes. 2. The adult variety, or Gonorrheal Ophthalmia, which may attack but one eye. Symptoms. — The period of incubation varies from 6 to 60 hours. The disease may be divided into three stages: Stage of infiltraticm, which lasts from 3 to 6 days; stage of pyorrhea, which lasts from 3 to () weeks, J)Isf:asks of thk conjunctiva. log and stage of chronic blennorrhea, which varies greatly in duration. r. Congestion of the palpebral'and ocular conjunctiva. 2. Pain is severe and of a smarting, burning variety. The great thickness and weight of the lids causes also a continuous dull ache in the eye. 3. Discharge is profuse and of a thin ichorous, beef juice kind in the first stage which changes in the second to thick yellow pus. 4. Swelling of the lids is so intense as to interfere with the proper inspection of the eye. When the pus begins to flow freely this swelling usually decreases. The conjunctiva becomes so edematous (chemosis) as to ox'erlap the circumference of the cornea. 5. Vision may be interfered with by the pus on the cornea, by corneal ulceration, or bv the inabilitv to raise the upper lid. 6. Ulceration of the cornea, the result of disturbed nutrition and infection, may supervene. This is the most dangerous symptom owing to the possibility of permanent scars, intra-ocular infection, and panoph- thalmitis. Cause. — Inoculation with gonorrheal ^•irus, the gonococcus of Neisser being found in the discharge. There are mild types which clinically simulate purulent conjunctivitis in which the gonococcus cannot be demonstrated. If the gonococcus is absent in the infantile variety, the disease has been caused by a vagi- nal discharge other than gonorrheal. Such cases are usually mild. If the gonococcus is absent in the adult form, the disease must be due to other pus-producing germs. It will sometimes follow mechanical and no LESSONS ON TOE EYE. chemical accidents or badly treated catarrhal conjunc- tivitis. A microscopic examination of the secretion should always be made. Treatment. — In the stage of infiltration cold applica- tions must be kept on the eye continuously. This may be done by keeping a number of small squares of muslin on a block of ice, and transferring one to the eye every Fig. 76. — Desmarre's lid elevator. minute. However, judgment must be exercised in the application of cold as it is a well-known fact that the puny and scrofulous bear it badly. The secretion should be washed away with a warm boric acid solu- tion (3 per cent.) , or some other mild antiseptic, about once every hour or oftener. The bowels should be well purged with salines and the patient kept as quiet as possible. If pain is very severe an adult may be given an anodyne. In the stage of pyorrhea the mechanical cleansing of the conjunctiva must be vigorously continued, but the greatest care must be taken not to injure the corneal epithelium. The upper lid should be turned once a day and its conjunc- tival surface painted with a i per cent, solution of nitrate of silver. In the place of nitrate of silver one of the less irritating silver preparations may be used. Protargol solution (5 to 20 per cent.) or argyrol solu- tion (10 to 25 per cent.) may be dropped between the lids every one or two hours. Argyrol is practically non-irritating and is probably the best remedy we DISEASES OF THE CONJl'XCTIVA. I I I ha\-c'. lM\'(iucnt irrisj;ali(>n with a i lo 5,000 solution of permanganate of potash is highly recommended. If the swelling of the lids is so great as to prevent eversion or to endanger the circulation, the outer canthus should be slit with a pair of scissors (canthot- omy). In the second stage ccjld applications should be diminished, if not altogether discontinued, owing to their depressing influence upon the nutrition of the cornea. If the cornea becomes hazy or shows a spot of Vu;. 77. — .\pplicatiun ni Huller's shield. (De Schweinitz.) ulceration the general treatment for corneal ulcers (page 140) may be followed as closely as is possible under the circumstances. In the third stage of the disease the treatment advised for chronic catarrhal conjunctivitis (page 107) should be followed. In adults, where one eye is affected, protect the good eye by covering it with a watch crystal held in position by adhesive plaster. This is called Buller's shield. As the secretion is most liable to get into the good eye LESSONS ON THE EYE. by flowing across the root of the nose, the shield should be well sealed at this point by the use of cotton and collodium. To prevent ophthalmia neonatorum in a child born of a diseased mother, resort to the method of Crede, which is to wash its eyes thoroughly just after birth and drop between the lids several drops of a five grain to the ounce solution of nitrate of silver. Crede advised a ten grain to the ounce solution, but this has proved unnecessarily strong. There is reason to be- lieve that argyrol or protargol, in the proper strength, may be as efficient prophylactics as the nitrate of silver. There is a law in many States punishing midwives and nurses for not immediately reporting, to a health officer, the appearance of inflammation in the eyes of a new-born under their care. A few convictions under this law would materially lessen the blindness from ophthalmia neonatorum. MEMBRANOUS CONJUNCTIVITIS. The characteristic feature of this inflammation is a plastic, fibrinous, pseudo-membrane on the tarsal and sometimes on the ocular conjunctiva. With the excep- tion of this membrane the symptoms are very similar to those of purulent conjunctivitis. It is customary to divide this affection into croupous and diphtheritic conjunctivitis, but since the disease appears in every degree of severity, from an almost harmless condition to one of a most destructive character, it is difficult to draw a dividing line clinically. Microscopic examina- tion of the secretion should be made at once. The DISEASES OF THE CONJUNCTIVA. II3 pneumococcus, streptococcus, staphylococcus or Klebs- Loeffier bacillus will generally be found. vSome of the most destructive cases reported ha\'e been due to streptococcus infection. Symptoms.— I. Congestion of the conjunctival vessels is hidden by the plastic membrane in severe cases. In a mild case, the plastic membrane being confined to the lids, the ocular conjunctiva will appear injected. 2. Pain is generally of an itching, burning character, but when there is great sweUing of the lid there is an added sensation of pressure on the ball. 3. Discharge is at first serous and flaky, and may be tinged with a little blood. As soon as the membrane begins to soften the discharge becomes purulent. 4. Swelling of the lids is almost imperceptible in the mild forms but in a severe case the upper lid may l)ecome so thick and tense as to render its eversion impossible. The exudation into the conjunctiva may be so excessive as to shut off the circulation, producing gangrene and subsequent cicatricial contraction and adhesions. 5. Vision is affected as in purulent conjunctivitis (page 109). 6. Ulceration of the cornea is produced as in purulent conjunctivitis (page 109). In mild attacks it rarely happens but in severe cases it is almost inevitable. 7. The membrane in mild cases is limited to the palpe- bral conjunctiva and can be mped off leaving a slightly bleeding surface. In severe cases it covers the entire conjunctiva and can only be removed by force, leaving a raw surface. 8. Constitutional symptoms will be ])resent when the 114 LESSONS ON THE EYE, disease is diphtheritic, and in severe cases due to other infections. Cause. — This must be determined by the microscopic findings. Treatment. — For mild cases follow the treatment recommended for catarrhal conjunctivitis (page io6) being careful though not to use nitrate of silver until the membrane has disappeared. Before the separa- tion of the membrane cleansing the conjunctival sac three or four times a day with an antiseptic solution (bichlorid i to 5,000) is advised. In the severe form follow the treatment as suggested for purulent conjunc- tivitis (page no) except that cold applications must not be used as continuously owing to greater danger of depressing the circulation, and nitrate of silver must be applied with caution and then not until the mem- brane has been thrown off. If the diphtheritic bacillus can be demonstrated constitutional treatment, includ- ing anti-toxin injections, should be instituted at once. LESSON XV. DISEASES OF THE CONJUNCTIVA (Continited). GRANULAR CONJUNCTIVITIS OR TRACHOMA. The characteristic feature of this disease is hyper- trophy of the conjunctiva and the appearance in that membrane of small granular bodies. Trachoma may assume three forms : I. Papillary trachoma in which the characteristic feature is hypertrophy of the conjunctiva. The nor- mal papillct? are greatly increased in size, hence the Fig. 78. — Granular upper lid. a, Granulations; b, line of scar, in typical position parallel with border of lid. (Nettleship.) name. This form is also called chronic conjunctival blennorrhea, as there is always a variable amount of pus in the discharge. Notwithstanding the absence of the trachoma follicles the conjunctiva undergoes cicatricial changes and the sequellae are practically the same as when the granules are present. 2. Granular trachoma in which the characteristic feature is the appearance in the conjunctiva of small IIS ii6 LESSONS ON THE EYE. follicles or granules. These follicles are composed of lymphoid cells and connective-tissue cells surrounded by an ill-defined fibrous capsule. They are imbedded in the fibrous layer and have a yellowish or grayish appearance. They develop later into connective tissue which undergoes cicatricial contraction. The follicles are most numerous in the fornix, but may be found in any part of the palpebral conjunctiva. KiG. yg. — Exuberant gramildtions. No indications of i icalri/.ation are pres- ent. (Jones.) 3. Mixed trachoma, which is the form under which we generally see the disease, is a combination of the two preceding varieties. Symptoms. — The eyes are irritable, giving distress under exposure or misuse. The lids may be swollen, and may droop a little. There is a slight muco-puru- lent or purulent discharge and there is a scratchy feel- ing under the lids. Upon inspection of the palpeliral conjunctiva the characteristic appearance abo\-e de- DISEASES OF THE CONJUNCTIVA. II 7 scribed will bo found. It the disease is of the papillary form the conjunctiva will have a rough or velvety ap- pearance due to the enlarged papilhe and the color of the swollen conjuncti\-a is of a slightly bluish tinge. There will also be some pus in the conjunctival fornix. If the disease is of the granular form the peculiar follicles will be present, but as stated above the usual picture is a combination of these varieties. With the progress of Fig. 80.— Trachoma and pannus. (Berry.) the disease all the symptoms increase in severity. Cicatricial changes will take place in the conjunctiva and even in the underlying tarsus, rendering the mucous membrane hard and fibrous in ])arts and by its contrac- tion bending the tarsus so as to produce trichiasis and its attendant evils. The ocular conjunctiva will be- come injected and pannus will develop (page 143). Ulceration of the cornea is a frequent complication and iritis may occur. Trachoma exhibits a marked tend- ency toward remissions and relapses. As a rule, the disease covers a period of years unless persistently and Il8 LESSONS ON '1"HE EYE. successfully treated. Some cases seem incurable; they will relapse until vision is practically destroyed. Cause. — Trachoma is generally conceded to be con- tagious, and the principle of the contagium is supposed to be a micro-organism. Numerous trachoma germs have been described, but none of them has as yet been accepted as the specific cause of the disease. The fact that one eye may be affected for years without infect- ing its fellow is adduced as an argument against the contagious theory. The tendency of the disease to spread in crowded institutions is in favor of this theory. Certain races, among which are the Jews and the Irish, show a predisposition to trachoma, whereas the negro of our Southern States is almost immune. Treatment. — Nitrate of silver, five grains to the ounce, applied to the conjunctiva of the everted upper lid, once a day or every other day, depending upon the effect, is a valuable remedy. When nitrate of silver is appHed to the conjunctiva a white coagulum is at once formed. The amount and rapidity of the forma- tion of this coagulum indicates the activity of the remedy. When the effect desired has been gotten the action of the silver should be checked by a few drops of a solution of common salt. During the above ap- plication the cornea should be protected as much as possible. Bichlorid of mercury solution (i to 5,000), protargol (20 per cent.) and argyrol (25 per cent.), are all useful agents. They should be applied directly to the conjunctiva of the upper lid. Rubbing them into the membrane with more or less force, by means of a cotton appHcator, has been recommended. These remedies are particularly applicable to the treatment DISEASES OF THE CONJUNCTIVA. II9 of papillary trachoma. For cases in which the f( )llicular feature predominates, the sulfate of copi)er, la])is divinus or alum stick is the best remedy. This should be apphed hghtly or thoroughly, daily or with longer intervals, depending upon the effect in each case. In mixed cases it is well to first reduce the papillary swell- ing with nitrate of silver, argyrol or bichloride of mercury, and then treat the granular trachoma with bluestone. Cold applications are often soothing and beneficial. In the late cicatricial stages ointment of yellow oxid of mercury (grains iv to the ounce) or corrosive sublimate (gr. 1/20 to the ounce) are recom- mended. Boroglycerid (30 per cent.) and glycerolc of tannin (5 to 25 per cent.) may be tried. For cases which cannot be seen regularly. Prince recommends copper sulfate in glycerin, six grains to the dram. A solution consisting of one drop of this to twenty drops of water should be made fresh every morning. Of the diluted solution, one drop should be instilled into the eye three times a day. Where the appearance of the granules indicates its feasibihty, squeezing them out with Knapp's roller forceps facihtates the cure. This should be thoroughly done under an anesthetic, and the hds subsequently treated with argyrol or bichlorid of mercury solutions. Old cases, in which there is considerable pannus, as shown in Fig. 80, are often greatly improved by the use of an infusion of jequirity. The cases on which jequir- ity is used should be carefully selected and as its use is sometimes attended with danger, this treatment should be left to an oculist. The use of jequirity or its substi- tute jequiritol will sometimes cause dacryocystitis. I 20 LESSONS ON THE EYE. ACUTE TRACHOMA. During the course of a clironic trachoma the diseased eyes may take on a se\-erc acute inflammation or the disease may seem to originate with an acute attack. Such an inflammation is spoken of as acute trachoma, hut is in reahty a case of chronic trachoma plus an acute conjunctivitis. Symptoms. — Rapid swelHng of the hds and hyper- trophy of the conjunctiva. Pain, which may extend to the brow and temples, lacrymation, heat, photopho- bia and congestion, with a muco-purulent discharge. The palpebral conjunctiva is swollen, red and shiny. I Si. — Knapp's roller forceps. The translucent granules, that are covered by the hypertrophied epithelium, usually are not seen until the acute symptoms subside. This occurs in from one to three weeks. It will often be impossible to distinguish this disease from acute catarrhal conjunctivitis until the granules appear. Treatment. — Apply iced compresses or the cold boric acid and tincture of opium solution recommended on page 1 06. Ten per cent, argyrol solution may be of service. Distress will sometimes be so great as to warrant the use of bromids or morphin. When the swelhng and pain have subsided and the granules appear, treat as a case of chronic trachoma. DISEASES OF THE CONJUNCTIVA. 121 FOLLICULAR CONJUNCTIVITIS. This disease is sometimes deseriVjed as a form of tra- choma, as they are frequently almost identical in ap- pearance. That there is a distinct difference is proven by the fact that follicular conjunctivitis never perma- nently injures the conjunctiva, whereas trachoma al- ways does. Symptoms. — The symptoms are those of an acute or chronic catarrhal conjunctivitis to which is added the appearance of the follicles in the fornix of the lower lid, Fu;. S2.— Follicular lonjunc tivitis. (After Klilc.) rarely in the upper lid. These granules, about the size of a pin head, are comp(ised of adenoid tissue, identical with that of the true trachoma follicle. They may be few in number or very numerous; if the latter, they are usually arranged in longitudinal rows. The disease is most frequent in children and young people and is very prolonged and ol;)stinate in its course. At times it gives so little annoyance that its presence is dis- covered by accident. Cause. — The etiology is obscure. It is supposed to be contagious as so many of the inmates of schools and institutions are attacked at the same time. Bad hygienic surroundings seem to be factors in the produc- tion of the disease. 122 LESSONS ON raE EYE. Treatment. — The same treatment as advised for acute or chronic catarrhal conjunctivitis is appUcable. An ointment of acetate of lead (gr. i to 5i) is recom- mended, but acetate of lead must never be used if there is any implication of the cornea. If the folHcles are prominent, expression with the roller forceps will hasten the cure. Fresh air, good food, proper exercise, attention to refractive errors and the proper use of the eves must not be overlooked. LESSON XVI. DISEASES OF THE CONJUNCTIVA (Continued). VERNAL CONJUNCTIVITIS, OR SPRING CATARRH. This is a disease of childhood or early youth. It affects both eyes and comes on with the advent oi warm days (hence the name), and will frequently last until cold weather. There is a tendency to recurrence in the same individual year after year. The attacks, however, gradually cease and no injurious sequelae are left. Symptoms. — The palpebral conjunctiva will be hy- peremic and the swollen papillce assume a flattened, rectangular shape. Frequently it appears to be over- laid by a bluish white film as if covered by a thin layer of milk. The ocular conjunctiva is usually hyperemic and in typical cases presents a narrow band of gray hypertrophied tissue at the limbus. This swollen mass may appear at the inner and outer side of the cornea or may entirely encircle it. Frequently it forms an arch over the upper half of the cornea. The thickened tissue is sometimes interrupted at intervals by depressions which give it a nodular or bead-like appearance. It usually encroaches upon the cornea for a slight distance. The objective symptoms may be Hmited to the changes in the tarsal conjunctiva (60 per cent.) or the circumcorneal hypertrophy may 123 124 LESSONS Ox\ THE EYE. 1)0 the only oljjective manifestation (lo per cent.), but a large number of cases ^vill present involvement of both (30 per cent.)- The subjective symptoms are a pricking pain, itching, heaviness of the lids, photophobia and some lacrymation. Treatment. — No remedy has yet been found of unquestioned service. Protection of the eyes from dust and wind and the use of dark glasses must be enjoined. The cold application on page 106 will be found comforting. The yellow oxid of mercury oint- ment may be tried. An ointment of salicylic acid, 2 per cent., rubbed into the conjunctiva once a day has been recommended. This treatment should be preceded by a drop of cocaine solution. One part of dilute acetic acid to 250 of water is said to relieve the pricking pain. The X-ray has seemed to cure some cases. Zinc, alum and ichthyol are recommended. PTERYGIUM. This is a triangular mass of hypertrophied con- junctiva, the apex of which encroaches upon the cornea, with the base generally toward the inner, sometimes toward the outer canthus. In rare instances an eye may have two pterygia, one on each side. The head or apex is firmly united to the cornea, sometimes going deep enough to destroy the membrane of Bowman. A pterygium rarely grows beyond the center of the cornea and usually it requires years for the apex to reach that point. While progressing a pterygium is red, fleshy and vascular (p. crassum), later, development ceases and it becomes thin, white, membranous and more or less bloodless (p. tenuis). It affects vision by growing DISEASES OF THE CONJUNCTIVA. I25 in front of the pupil or by traction producing astig- matism. Cause. — It is found usually in those whose eyes are subjected to the irritation of wind and weather. Fuchs claims it is developed from a pinguecula, others main- tain that its starting-point is an erosion of the corneal limbus. La\'men ^^"ill usuallv call this growth cataract. I'"i<".. 83. — Pteryj^iuni. C, caruncle; P, punctum; S, probe passed under the upper margin. (Fuchs.) Treatment is operative. False pterygiiiui partakes of the character of a symblepharon. It is an in- flammatory adhesion of the ocular conjunctiva to a denuded or ulcerated point of the corneal limbus which is the result of acute blennorrhea, diphtheria, burns or injury. It can be differentiated from true pterygium by its history, the fact that it may appear at any point on the circumference of the cornea, and that it has no tendency to progress. PINGUECULA. This is a small yellow elevation in the conjunctiva, generally found between the limbus of the cornea and 126 LESSONS ON THE EYE. the plica semilunaris, but sometimes on the temporal side. It is composed of connective tissue and elastic fibers. It is of frequent occurrence, does no harm and need not be removed. SYMBLEPHARON. This is a cicatricial adhesion between the conjunctiva of the lid and the conjunctiva of the ball and is the result of the apposition of two raw surfaces, which may Symblepharon. have been produced by operations, ulcers, burns, etc. The treatment is operative and difficult. After dissect- ing the lid from the ball the raw surfaces must be thoroughly covered by mucous membrane or they will promptly reunite. Burns of the conjunctiva are serious because they lead to the adhesion between the hds and globe just described. Powder burns may only involve the outside of the lids and may, if the eye is not closed quickly enough, seriou.sly damage the cornea and entail loss of sight. DISEASES OF THE CONJUNCTIVA. 1 27 The burns of percussion caps and torpedoes are espe- cially destructive, owing to the added evil of the chem- ical action of the fulminate of silver and mercury of which they are made. All the foreign particles should be carefully picked out of the skin and cornea, an ano- dyne given to control the pain, and the eye put u]) in an aseptic castor oil dressing. If the cornea is much injured atropin should be used, as there is danger of secondary iritis. Beard suggests antiseptic and anodyne treatment for two or three days, then the use of H.O,. The tissue around the foreign bodies has by this time become softened and the gas generated by the per- oxid lifts out the particles of powder. Lime burns must be w^ashed copiously with tepid water and all particles picked out with forceps if an anesthetic has to be given to accomplish it. An anodyne can be given and holocain used locally. Adhesions should be broken every day and sweet oil or castor oil dropped between the lids. If the l)urn is deep symblepharon will follow. It has been found by zur Nedden that the corneal opacity soon changes to carbonate of lime and when this takes place Httle can be done. He recommends the immediate free application three times a day of a 5 or 10 per cent, solution of ammonium tartrate neu- tralized by the addition of liquor ammonia?. Acid burns should be thoroughly cleansed with weak bicarbonate of soda solution, and the raw surfaces, pain and inflammation combated as in the case of lime burns. Atropin should always be used where there is danger of iritis. 128 LESSONS ON THE EYE SUB-CON JUNCTIVAL ECCHYMOSIS. A hemorrhage under the conjunctiva may be due to a strain, traumatism or disease of the blood vessels. It is seen often in children with whooping cough, and need cause no uneasiness. Coming on in an adult, without strain or accident, it indicates weakness of the vessel walls and portends hemorrhages in other organs, which might be of serious consequence. There is no pain attending the condition and treatment is unnecessary. Hot applications may hasten absorption of the clot. MORBID GROWTHS IN THE CONJUNCTIVA. The abnormal growths which may develop in the conjunctiva will only be mentioned. The diagnosis and treatment of these conditions lie along surgical lines. Thickeninji of the lower lid flue to a mass of tul)crcular ncdules. The conjunctiva may be the vSite of a j)nmar)- syph- ilitic sore, or a secondary mucous patch and a ter- tiary gumma of the conjunctiva has been reported. Tf a true chancre is jircstMit the ])reaiincu]ar and DISEASKS ()|- rilK CONJUNCTIVA. 129 submaxillary ^^lands will be swollen. Treat mcnt is constitutional. Tuberculosis of the conjuncti\-a, though a rare disease, is now being more often recognized. It may appear in a number of forms but most frequently occurs as an ulcer. The next most frequent variety is that characterized by yellowish subconjunctival nodules which may be mistaken for trachoma folHcles. The detection of conjunctival tuberculosis often requires fine diagnostic discrimination. EpitheHomata and sarcomata may develop, and usually elect the limbus as their starting-point. Thorough removal is im- perative. Some cases demand sacrifice of the eyeball and orbital contents, but even this does not always save the patient. Lipomata are found under the conjunctiva, between the superior and external rectus muscles and must be differentiated from a dislocated lacrymal gland. Papillomata may grow from any part of the conjunctiva, while dermoid tumors are, as a rule, found as congenital formations, near the outer canthus. Cysts, nevi and angiomata are also found in the conjunctiva. LESSON XVII. DISEASES OF THE CORNEA. PHLYCTENULAR KERATITIS. Phlyctenular keratitis and phlyctenular conjunc- tivitis are the same disease, the only difference being in the location of the vesicle. The small nodule, which is the characteristic feature of the disease, may be located on the scleral conjunctiva or on the cornea, but is most frequently found between the two, at the limbus. When on the cornea, all the symptoms are more severe than when the disease is conjunctival, and Fig. 86. — Phlyctenular conjunctivitis, (.\fler Dalrymple.) it is only when corneal that it can leave any changes which impair vision. The numt»er of vesicles is not limited, and it is possible to ha\-e them on the cornea and conjunctiva at the same time. Symptoms. — The so-called vesicle, a small nodule (red if on the conjunctiva, gray if on the cornea), is at first a circumscribed accumulation of leucocytes, 130 DISEASES OF THE CORNEA. J _:; J under the epithelial layer, l)iit soon develops into an uleer. The conjunctiva is injected, and there is a tendency of the enlarged vessels toward the phlyctenule. Photophobia and pain are severe, which produces strong blepharospasm. The child will keep its face in the dark and any effort to bring it to the light, for the purpose of examination, will meet with strong resistance. Lacrymation is pronounced. Marginal KlG. 87. — Phlyctenular keratitis, (.\fter IwanotT.) This consists of a collection of pus cells between the epithelium and the substantia projiria. The band passing obliquely to it is a corneal nerve. blepharitis is often present. Generall}' there is a discharge from the nose, and eczematous scabs form around the lips and nostrils. There may be enlarge- ment of the lymphatic glands and other evidences of a strumous diathesis. Usually the disease recovers in a few weeks, leaving no permanent injury, but relapses are the rule. Faint opacities of the cornea may be left, which, if over the pupil, will impair vision. In rare instances deep ulceration of the cornea may develop, followed by secondary iritis, perforation or staphyloma. Cause. — It is a disease of childhood, and is supposed to be due to some irregularity of nutrition, the result of the strumous diathesis. Leitner found scrofulosis 132 LKSSONS ON THE EYK. present in 88.7 per cent, of the 585 children with phlyctenular conjuncti\'itis examined by him. Bad hygienic surroundings and insufficient nourishment seem to contribute to the disease, and yet it is frequently seen in otherwise healthy children. Treatment. — The cause being constitutional, give fresh air, wholesome food, tonics of syrup of the iodid of iron, malt or cod liver oil, and keep bow^els regular. Small doses of calomel are efficacious. Dusting the Fig. 88. — Phlyctenular ulcer. cornea with finely powdered calomel, once a day. is recommended but must not be done if the patient is taking potassium iodid. Promote health in every way. Tubercular subjects should receive treatment ap- propriate to this disease. Use locally hot fomentations and a weak ointment of yellow oxid of mercury rubbed in gently once a day. Atropin is often indicated. If pronounced corneal ulceration develops, follow the treatment for such a condition (page 140). Consti- tutional treatment should be continued after the dis- appearance of the local disease. INTERSTITIAL KERATITIS. This is a disease of childhood but may ])e found in adult life. Both eves arc usualK' in\ol\-c(l, one in DISEASES OF THE CORXEA. 133 ach'ance of the other. The suhstaiUia ])ro])ria is the part primarily involved The deep layers soon par- ticipate in the inflammation, and in severe cases the uveal tract rarely escapes. The course of the disease is chronic, sometimes extending over two or three years. Relapses are common. The prognosis is favorable, although only a few cases escape without some im- pairment of \'ision. In a limited number sight is permanently lost. Fig. 89. — Interstitial keratitis. (Nettleship.) Symptoms. — At first the eye will indicate a state of irritability. There will be some photophobia, lacry- mation and circumcorneal h}'peremia. Vision will become blurred and inspection will reveal an infiltra- tion of the deeper layers of the cornea, which gives it an opaque or hazy appearance. This haziness may begin in the center or it may start from the scleral margin. Small blood vessels will be seen springing from the corneal periphery and extending toward its center. These blood vessels are deep in the substantia propria and if numerous will give the inflamed area a salmon pink color. The opacity of the cornea may become complete in a short time and vision be reduced to light perception. Iritis may occur, with a tendency toward the inflammation extending to the ciliarv body 1 U LESSONS ON THE EYE. and choroid. When resolution sets in the opacity begins to disappear at the margin, the center of the cornea being the last part to become transparent. When the iris can be seen, posterior synechiae may be found and when the fundus can be examined we may find evidences of choroidal inflammation. Associated with the eye symptoms we generally find e\-idences jmm^ ^ Fig. 90. — Hutchinson's teeth. .^Iso the syphilitic scars at the angles of the mouth. of inherited syphilis; glandular enlargement, sunken nose, ozena, Hutchinson's teeth, scars at the angles of the mouth, the vaulted palate and the -characteristic physiognomy. Cause. — Nettleship claims to have found evidences of inherited syphilis in 68 per cent, of his cases, and suspects it in the remaining 32 per cent. However acquired, syphilis, tuberculosis and traumatism were the undoubted causes of numerous cases reported. It is said also to be caused by scrofula and rheumatism. Tr€at]}ient. — Use smoked glasses to protect the eyes DISEASES (JF TllK CORNEA. I35 from the light. Apply hot appHcatioiis lor thirty minutes at a time three or four times a day. Drop into eyes, twice a day, a i ])cr cent, solution of sulfate of atropin. Use atropin more frequently if necessary to keep the pupil dilated. Unless the symptoms point conclusively to some other cause assume the existence of syphilis and give anti-syphilitic remedies with tonics, good food and good air. After the acute symptoms have subsided use a w^eak ointment of the yellow oxid of mercury (grs. 2 to o^) putting into the conjunctival sac, once a day, a quantity al:)out half the size of a pea. The ointment can be thoroughly disseminated, and at the same time a massage of the cornea effected, by placing a finger on the closed lid and giving it a gentle lateral or rotary movement. Dusting the cornea with calomel has been recommended, but it must be remem- bered that calomel should never be put into an eye when the patient is taking iodid of potassium, as the iodid is found in the tears and with the calomel makes an intensely irritating compound, mercuric iodid. If the massage with the yellow oxid of mercury ointment or the dusting with calomel causes undue reaction, it indicates that the remedy has been employed too soon and its use should be postponed until the eyes are less sensitive. Cases which are tubercular in origin may be improved by injections of tuberculin. When the acute symptoms have subsided dionin may be used to promote the absorption of the deposits which cloud the cornea. LESSON XVIII. DISEASES OF THE CORNEA (Continued) ULCERATION OF THE CORNEA. Symptoms. — Congestion, pain, lacrymation, impair- ment of vision and swelling of the lids are associated with ulceration of the cornea, but the latter, being due to such a diversity of causes, will show a great variety of symptomatic pictures. For exam])le, an eve with Fig. ()j. — A. large superficial ulcer of the cornea. The ulcer is surrounded by a zone of infiltration. ulceration of the cornea resulting from diphtheritic conjunctivitis will necessarily present a \'ery different appearance from one in which the ulcer is due to an infected foreign body. Corneal ulcers have also been accurately classified according to shape, method of development and cause, but for the purposes of the student a general description is deemed sufficient. 136 DISEASES OF THK CORNF.A. 1^7 The part of the eornea inx'oh'ed beeomes infiltrated and appears hazy, white or yeUow. This is quickly followed by a loss of corneal substance. The destruc- tion of tissue may spread superficially or may involve the deeper layers and result in speedy perforation. The ulcer wnll be surrounded by a hazy zone of infiltrated tissue, the region of densest infiltration correspond- ing to the directicMi in which the ulcer is most liable to progress. If the disintegrating y)rocess only in\-olves the first two lavers, re])air \\'ith trans])arent tissue will Fig. 92. — Beginning corneal ulcer. (After Sacmisch.) The upper layers of epithelium are partly lacking. .\t Bowman's membrane a layer of pus- cells is seen. In the substantia ])roj)ria are numerous small grou])s of [lus- cells. result, but any loss of the deeper layers will usually be replaced by an opaque scar. An ulcer will meet with greater resistance from the membrane of Descemet than from any other layer of the cornea, and is often checked at this point. If Descemet's membrane gives way, perforation follows. When this takes place the aqueous escapes and the iris and lens come forward to the cornea. If the iris adheres permanently to the corneal cicatrix, we have a condition called anterior synechia. Contact of the anterior lens capsule with the cornea is liable to produce an opacity of the capsule 138 LESSONS ON THE EYE. at the point of contact if the i)atient be \ery young. When the aqueous escapes the tension is reheved and the lymph circulation in the cornea becomes freer, which accounts for the improvement so often noted after perforation. Iritis occurs frequently and is sure to occur if the deeper layers of the cornea are involved. Adhesion of the iris to the lens capsule or posterior synechia must be guarded against. The cihary body mav become involved. In some cases there is an exuda- FiG. 93. — Ulcer of the cornea. The epitheHuni^ Bowman's membrane and part of the substantia propria are gone. The floor of the ulcer is infil- trated with pus-cells. tion of non-pathogenic pus from the iris which forms at the bottom of the anterior chamber. Pus in the anterior chamber is called hypopyon. The presence of hypopyon adds gravity to the disease, and in such cases the prognosis should be extremely guarded. The entire cornea may melt away and the eyeball still be preserved by the formation of a white, fibrous cicatrix where the cornea was. This new tissue may not be as resisting as the cornea, and is liable to be protruded by the intra-ocular pressure, causing staphyhmui (page DISEASES OF THE CORNEA. 1 39 145). After perforation intra-oeular infeetion may occur and the eye be destroyed 1)\- pauophthaliuitis (page 171). Cause. — The exciting cause is a pathogenic microbe, generally the white or yellow staphylococci, the pneu- mococcus, the streptococcus, the diplobacillus, the gonococcus. the xerosis bacillus, the aspergillus fumi- gatus or the bacillus pyocyaneous. The source of the germ ma>- be purulent conjunctivitis, dacryo .( - :--^^ Fig. g4. — The cornea after ulceration, showing the scar tissue. cystitis, erysipelas, diphtheria, ozena, septic fingers, handkerchiefs and instruments, or an unknown source. The predisposing cause is some condition which renders the cornea more susceptible to infection. This mav be a debilitating disease, an injur}^ from a foreign bodv, an operation, lagophthalmia (paralysis of the seventh nerve), or paralysis of the fifth nerve. The ulceration due to paralysis of the fifth is called neuro- paralytic keratitis. With paralysis of the fifth there is loss of sensation, foreign bodies are no longer removed 140 LESSONS ON THE EYE. from the cornea, Vjy the reflex action of the lids, and abrasion results. Abrasion is further facilitated by the dryness of the cornea which exists in the absence of winking. Treatment. — When the ulcer is due to purulent con- junctivitis, dacryocystitis, erysipelas, diphtheria, etc.. the primary disease must be treated vigorously. Mi- croscopic examination of the necrotic tissue should be made in order to identify the responsible germ. If the secretion is scant the lids should be immobilized, V)e- FiG. 95. — Perforating ulcer of the cornea, adhesion of iris (anterior synechia). tween treatments, by a light bandage, if abundant the bandage should not be used. In some cases it is best to keep the eye hermetically sealed between the daily antiseptic dressings. The focus of germs should be destroyed by touching the ulcer with a galvanic cauterv, tincture of iodin, carbolic acid, 20 per cent, trichlor- acetic acid, I to 100 formal, or by scraping it clean with a small curette. This should be done under holocain (i per cent.) anesthesia. Holocain is preferable to cocain as it does not dry the corneal epithelium, and also possesses some antiseptic properties. The con- junctival sac should be cleansed out about three times a day with bichlorid or cyanid of mercury solution" I to 8,000. The cleansing may be repeated more fre- DISKASKS OK THK CORNKA. I4I (lucnlh- if a saturated solution of l)()racic acid or bihoratc of soda is used. The direct applicaticMi of a stron^^ protargot solution (20 per cent.) has been extolled. Argyrol (10 to 40 i)er cent.) may be used. Zinc in some form should be freely applied if the ulcer is due to the diplobacillus of Morax and Axenfeld. Dionin is said to stimulate corneal regeneration. Covering the ulcer with finely powdered nosophen or xeroform is advised. Hot fomentations should be applied for thirtv minutes at a time everv four hours. Abcnit Fig. 96. — Hypopyon, seen from the front, and in section, to sliow that the pus is behind the cornea. (Nettleship.) three times a day instil a drop of a i per cent, solution of atropin to relieve iritic congestion and prevent posterior svnechia. Some advise the use of eserin to relieve intra-ocular tension and thus improve the lymph circulation in the cornea, but this is manifestly dangerous if the iris is involved. The value of sub- conjunctival injections and the serum treatment is still undetermined. Paracentesis will relieve the tension, and is sometimes indicated, especially if perforation is imminent. The patient should be kept quiet and the constitution sustained by iron, quinin, and strychnin tonics. The internal administration of large and fre- quent doses of dilute sulfuric accd seems to create a 142 LESSONS ON TllK EVE. conditicjii in the tissues antagonistie tu ])us formation. It has, at times, appeared to check the ulcerative process in the cornea. If the ulceration is neuropara- lytic or is due to paralysis of the seventh nerve, the cornea must be protected by the lid and a bandage or adhesive plaster will be necessary to accomplish it. LESSON XIX. DISEASES OF THE CORNEA (Cond) AND SCLERA. VASCULAR KERATITIS OR PANNUS. The upper half of the cornea is the part most frequently affected, but its whole surface may be involved. It becomes grayish in color from cellular infiltration and covered by a mesh of fine blood vessels, which grow from the conjunctiva. The infiltration and vascularity are found between the epithelial and Bowman's layers, ii^'^^^ "mm Fig. i)-j. I'annus. (Kick.) but may go deeper. If the new growth inxades the substantia propria permanent scarring is the result. Vision is impaired and may be reduced to hght percep- tion. As pannus is secondary to some other ocular disease, the general symptoms will be those of the pri- mary affection. Cause. — Pannus is most frequently caused ])y tra- choma, pannus trachomatosus. Repeated attacks of phlyctenular keratitis may result in pannus scrofulosa. 143 144 LESSONS ON IHK KYF.. Ingrowing lashes, irritciticjn of the eornea from imper- fect closure of the lids, etc., produce traumatic pannus. Treatment. — Attend to the primary disease. The use of an infusion of jequirity produces a severe purulent inflammation, which often results in great improve- ment and sometimes cure of the pannus, but this treat- ment should be left to an oculist. Fox recommends the operation of peridectomy, which consists in excising a strip of bulbar conjunctiva 2 to 5 mm. wide immedi- ately surrounding the cornea. OPACITIES OF THE CORNEA. Nebula, macula, and leucoma are names given to different degrees of opacity of the cornea. These opaci- ties usually represent scar tissue, which has replaced the loss of substance occasioned by an ulcer, but they may be due to an infiltration or a traumatism. If the first two layers of the cornea are destroyed they may heal without leaving any sign, but any loss of the deeper layers is generally repaired with scar tissue. The amount of damage to sight produced by an opacity depends upon its location relative to the pupil. Recent scars are improved by time and direct massage with a stimulating ointment, but old ones will remain un- changed. The persistent use of dionin has been bene- ficial. If the opacity is central and there is any per- ipheral clear cornea, an artificial pupil may improve vision. Before advising an iridectomy it is wise to dilate the pupil to the maximum extent and observe if this measure improves vision ; if not, a false pupil will be of little service. At times vision is much impaired DISEASES OF THE CORNEA. 145 by opacities which are so faint that they may be overlooked by inspection, even with obhque illumina- tion. With an ophthalmoscope and transmitted light they will be seen. The exact locality of such an opac- ity, whether in the cornea, anterior or posterior part of the lens, is often not easy to determine (Fig. 98). Fig. 98. — Localization of opacities in cornea and lens. STAPHYLOMA. Severe ulceration of the cornea so decreases its power of resistance that the normal intra-ocular pressure may cause it to bulge forward, destroying the natural curve. The distention may involve the whole cornea or only part of it. When staphyloma is the result of a perfo- rating ulcer, the iris may be caught in its tissue. This anterior synechia may cause recurring attacks of iritis and even deeper intra-ocular inflammation. The staphylomatous cornea is never transparent. It mav 146 LESSONS ON THE EYE. be stationary or progressive. It may be small or so large that the lids will not close over it. In some cases nothing need be done. The treatment is operative. Fig. 99. — Total staphyloma. (Pick.) ARCUS SENILIS. A narrow white ring is often seen near the circumfer- ence of the cornea. It is usually found in old people, Init may occur in the young. It is caused by hyaline Fig. -.\n arcus senilis. degeneration and requires no treatment. It has no influence on the healing of wounds, as for examjile the incision in cataract operation. DISEASKS OF THE CORNEA. 147 CONICAL CORNEA, OR KERATOCONUS. Sometimes the centerof the cornea becomes weakened by an atrophic ]jrocess and the intra-ocular pressure pushes it forward ; the convex sphere changing to a cone. The cornea remains clear except for the occasional appearance of a nebula at its apex. The process is slow and gradual but finallr reaches a point w^here it stops. Kenitoa (Afu Vision is greatly impaired. Inspection of the eye reveals no abnormality, except in pronounced cases, when a side view will show its conical form. Diagnosis in the early stages is difficult and treatment not very effective. The latter should be left to an oculist. FOREIGN BODIES IN THE CORNEA. It is very common for cinders, sand, pieces of emory, iron, steel, etc., to become lodged in the cornea. Pain and lacrvmation will be intense, with more or less cir- 148 LESSONS ON THE EYE. cumcorneal injection. If simple inspection does not reveal the offender, use oblique illumination. This is done by seating the patient about two feet from a light and with a i6 or 20 diopter convex lens, focus the rays Fig. 102. — Spud for remc f<)reic;n bodies. obliquely on the part to be examined. Then by viewing the illuminated area through a magnifier, the cornea, iris, and anterior part of the lens may be thoroughly inspected. One of the binocular magnifiers is indispen- FiG. loj. — ObliquL' illumination. sable in such work. To remove a foreign body, the cornea should first be anesthetized by several drops of a 4 per cent, solution of cocain or a 1 ])er cent, solu- tion of holocain; ihcn, with a needle or s])U(l ])ick it out niSKASKS Ol' THK SCLKKA. M*) with as liUk' destruction to corneal tissue as possible. When the epithelium is denuded there is always danger of infection; therefore, an antiseptic collyrium (solution hydrarg. bichlorid i t(^ 8,000) should be used for three or four days, or until the epithelial layer is restored. Another way to prevent infection of the cornea when the epithelium has been denuded, is to touch the lesion lightly with compound tincture of benzoin. A thin, adherent ])ellicle is immediately formed, which covers the wound for from six to twelve hours. Probably the safest way to pre\-ent infection is to clean the eye antise]^tically and seal it up between daily dressings. DISEASES OF THE SCLERA. EPISCLERITIS. Under the ocular conjunctiva is a delicate membrane, the capsule of Tenon, and between the capsule of Tenon and the sclera proper is the loose connective tissue called the episclera. These parts are so intimately related that inflammation of the subconjunctival tissues generally involves the overlying conjunctiva and may go deeper into the sclera proper. Scleral and episcleral inflammation is limited to the region anterior to the equator. Symptoms. — In episcleritis there appears a patch of dusky red injection under the conjunctiva, generally between the insertion of a rectus muscle and the cornea. There may be a distinct nodule which will tend to con- found the disease with phlyctenular conjunctivitis. The age of the patient and the fact that the episcleral nodule does not ulcerate will aid in the differentiation. The 150 LESSONS ON THE EYE. discliars^a' from the eye is watery and pain and i)hoto- pholjia arc generally slight. The inflamed spot may disappear spontaneously, may persist for weeks, has a tendency to recur, and will often leave a gray, discolored patch. Cause. — Rheumatism, gout, tuberculosis, syphilis, and menstrual derangement. It may arise from exposure to the weather and is also said to appear over the inser- tion of a rectus muscle suffering from insufficiency. Frequentl}* the cause is obscure. Treatment. — Some cases are so mild as to need no treatment. The constitutional cause, if discoverable, should be attended to. Correct muscular anomalies and refractive errors. Apply hot fomentation. Use atropin, if there is any tendency toward iritis. When chronic, stimulation with yellow oxid of mercurv oint- ment is useful. SCLERITIS. Inflammation of the sclera may be circumscribed or diffuse. It resembles episcleritis, but the symptoms are all more severe and, as a deeper structure is inflamed, there is much greater danger of involvement of the uvea. The discharge is watery and pain and photophobia may be pronounced. The inflammation may extend to the underlying uveal tract and produce iritis, cyclitis, or choroiditis ; or extend to the cornea, producing a haziness of its deep layers (sclero-keratitis) . These complica- tions may lead to an impairment or total loss of vision. Tension is often increased. The condition is chronic in its course, sometimes extending over a period of years. The scleral wall may become so thinned that the dark DISEASES OF THE SCLERA. I5I uvea showing throui^h il will <^\yc it a puri)lish hue. The imperfect resistance of the thinned sclera will result in bulging or staphyloma of its weakest parts. Cause. — The cause is generally rheumatism, gout, syphilis, tuberculosis, or menstrual disorders. Fig. 104. — Staphyloma of the sclera. Treatment. — For the syphilitic form use mercury and iodid of potassium. In scrofulous cases, tonics, good air, and good food. When due to rheumatism, salicy- late of sodium, Rochelle salts, etc. If gouty in origin, iodid of potassium or colchicum. Combine above treatment with hot baths, warm fomentations over eyes, leeching of the temples, and atropin locally. The increased tension and staphyloma may be improved by a wide iridectomy. LESSON XX. DISEASES OF THE IRIS. Mydriasis or dilatation of the pupil may be due to many causes, among which are: 1 . The use of drugs called mydriatics, such as atropin, homatropin, scopolamin, andcocain. Most mydriatics also produce paralysis of accommodation. 2. Increase of intra-ocular pressure, as in glaucoma. 3. Loss of vision, as in atrophy of the optic nerve. 4. Paralysis of the third nerve. 5. Dimness of light. 6. Ingestion of certain drugs, belladonna, ergot, etc. 7. Apoplexy in the later stages. Myosis or contraction of the pupil may be due to : 1. The use of drugs called myotics, such as eserin and pilocarpin. The myotics also stimulate accom- modation. 2. Evacuation of the aqueous humor. 3. Hyperemia of the iris, as in iritis. 4. Paralysis of the cervical sympathetic nerve. 5. Bright light, accommodation and convergergence. 6. Ingestion of certain drugs, as opium and alcohol. 7. Apoplexy in the early stages. The Argyll-Robertson pupil is one which responds to convergence but not to light, and is significant of locomotor ataxia. The variations of mydriasis and myosis dependent u]^()n irritation and disease of the 152 DISEASES OF THE IRIS. 153 brain and spinal cord arc loo complex to dwell u})on here. Anterior synechia is an adhesion of the iris to the cornea, due to perforation of the cornea and lodgment of the iris in the wound. Posterior synechia is an adhesion of the iris to the anterior capsule of the lens. In complete posterior Fig. 105. — Posterior synechia. synechia we have what is called exclusion of the pupil. Where the pupillary area is filled by a membrane, we have occlusion of the pupil (Fig. 107). IRITIS. The disease may be divided by its course into acute or chronic; pathologically it may be plastic, suppura- tive or serous; etiologically it may be divided into as many forms as there are causes, the leading varieties being syphiHtic, rheumatic, gouty, tubercular, and traumatic. The typical form of iritis is plastic; serous iritis, according to Colhns, Priestley Smith, and others, being more appropriately a cyclitis. PLASTIC IRITIS. Symptoms. — Injection of the deep blood vessels around the cornea, later extending over the entire 154 LESSONS ON THE EYE. white of the eye. Diseharge of a watery eharacter. Intolerance of Hght and pain of a neuralgic nature, beginning in the eyeball and extending over the brow, temple, and cheek. The pupil becomes small and will not react to light. Its normal color changes to a darker tone, a blue or gray iris becoming green. The Fig. io6. — Congestion of iritis. The circumcorneal zone the first part to become injected. See Fig. 74. aqueous becomes turbid from lymphoid cells, pus, and red blood corpuscles, and vision is correspondingly im- paired. Adhesion will take place between the iris and anterior lens capsule, constituting posterior synechia. If these adhesions are broken, pigment deposits will be left on the capsule of the lens. When the attack is syphilitic in origin, gummata may develop in the DISEASES OF TOE IRIS. 155 iris. If there is iniieli ]»us in the acjueous humor it may settle in llie anterior elianiher, ])ro(lneini^- hypopyon. Sometimes the e.xudation in the anterior ehamber leaves a membrane across the pupil which may be mistaken for cataract. Such a condition is spoken of as occlusion of the pupil (Fig. 107). Iritis may attack one eye or both. Its duration depends largely upon k r Fig. 107. — Exclusion and occlusion of the pupil, with bulging of the iris forward from accumulation of fluid in the posterior chamber. The posterior chamber (h) is thus made deeper, the anterior chamber (v) shallower, espe- cially where the root of the iris (a) is pressed against the cornea. The ])Upil is closed by an exudate membrane (o). (Fuchs.) the treatment, but will generally last from two to six weeks. In some cases the eye will be slightly myopic for weeks after an attack of iritis. Cause. — In 50 per cent, of all cases it is due to syphilis, secondary, tertiary, acquired, or inherited. The next most potent factors are rheumatism, gout, tuberculosis, and gonorrhea. It may arise as secondary to other eye diseases or be due to direct lesions, acci- dental or operative. Albuminuria, diabetes, mumps, disease of the nasal sinuses, and bad teeth are also said to be etiological factors. 156 LESSONS ON THE EYE. 'J'rculiiioit. Prohibit ^^■ork and protect eyes with shaded glasses. Look to the general health of the patient, paying special attention to the condition of the alimentary canal. To prevent posterior synechia, dilate the pupil with atropin and keep it dilated through the whole attack. Leeching at the temple is sometimes efficacious. For the pain, give antipyrin or morphin and apply heat, dry or in the form of watery fomenta- tion. The daily instillation of several drops of a 2 per cent, solution of dionin has a decided influence in lessen- ing the pain and also seems to shorten the duration of the attack. When dropped on the eye it causes a burn- ing sensation, which can be prevented by preceding it with a drop or two of cocain. The constitutional treat- ment will depend upon the cause. In syphilitic cases give mercury and iodid of potassium. When rheumatic or gouty in origin, use the salicylates, colchicum, lithia, etc., combined with hot baths or pilocarpin sweats. Iridectomy has been suggested for recurring iritis, and paracentesis is advisable in some cases with increased tension. SUPPURATIVE IRITIS. This form is generally due to wounds or operations and does not differ materially from the plastic form, except that the presence of pus infection makes the symptoms more severe and the prognosis very grave. It may also be due to infectious diseases, pyemia, and meningitis. SEROUS IRITIS. This disease and serous cyclitis are the same ; not only are the iris, ciliary body, and the choroid involved, but DiSKASKS or Tni; iris. 157 also Descemel's membrane of the cornea. It has been described under the names descemitis, keratitis postica, keratitis punctata, serous uveitis, and serous irido- cycHtis. Symptoms. — Shght pericorneal injection, pain insify- nificant, vision sometimes only a little below nr)rmal, but maybe much lowered, increase of aqueous evidenced by unusual depth of the anterior chamber and plus ten- Fig. 108. — Serous iritis. sion. The pupil will not be contracted as in plastic iritis and the iris will only be slightly discolored. Pos- terior synechia may occur, but is not as common as in other forms of iritis. There will also be found a char- acteristic cellular deposit in the form of fine dots on the lower half of the posterior surface of the cornea, which constitutes keratitis punctata. The course of the dis- ease is more or less chronic and the subjective symptoms mild as compared with the other forms of iritis. Cause. — The causes are the same as in plastic iritis. Treatment. — The same as in plastic iritis except that atropin must be carefully used, owing to the danger of increasing the tension. If the tension becomes danger- ous" it may be reduced by the cautious use of pilocarpin locally or pilocarpin injections, to produce diaphoresis Paracentesis may be necessary. LESSON XXI. DISEASES OF THE CILIARY BODY AND VITREOUS. DISEASES OF THE CILIARY BODY. Inflammation of the ciliary body is not an isolated condition, but is probably always associated with dis- ease of the iris or choroid. Cychtis may be acute or chronic; plastic, suppurative, or serous. PLASTIC AND SUPPURATIVE CYCLITIS. The symptoms of these two conditions are the same as in iritis, with the addition of opacity of the vitreous, severe pain upon pressure over the region of the ciliary body and characteristic tension, which is plus in the acute stage, but later may become decidedly minus, due to atr()])hy of the ciliary body and shrinkage of the vit- reous. The lens sometimes becomes opaque and detach- ment of the retina may occur. Plastic cvclitis is dan- gerous; suppurative cyclitis is almost always fatal to vision. Treatment is the same as in iritis. SEROUS CYCLITIS. This is the same as serous iritis (page 156). SYMPATHETIC OPHTHALMIA. Sympathetic ophthalmia is a diseased condition aris- ing in one eye caused by some organic lesion of its fel- 158 DISEASES or THE VITREOUS. 1 59 low. The eve whieh is first alTeeted is called the exciting eye, while the other is ealled the sympathizing eye. The disease takes two forms— sympathetic irritation and sympathetic inflammation. Symptoms. — (i) Sympathetic irritation is a func- tional derangement characterized by intolerance of light, lacrymation, and fatigue of the eye when used. Visual acuity may be impaired and sometimes tempo- rary obscuration of sight occurs. There may be con- siderable pain, of a neuralgic character, in and around the eye, and also some pericorneal injection. The symp- toms may subside, but a relapse will occur. Unless the exciting eye is enucleated, the disease is prone to develop into sympathetic inflammation. (2) Sympathetic inflammation is sometimes very slow and insidious in its development. It may develop rapidly and without any premonitory symptoms. When established there is intense circumcorneal injec- tion, an inflamed iris, contracted pupil, punctate depos- its upon Descemet's membrane, lowered vision, opaci- ties in the vitreous, intense neuralgic pain in the region supplied by the fifth nerve ; also pain upon pressure over the ciliary region. The ophthalmoscope may reveal a swollen disc and edematous retina. The iris, ciliary body, and choroid are involved in a chronic plastic uveitis which usually results in total blindness. As the disease progresses, synchysis of the vitreous, detach- ment of the retina, and atrophy of the ball will develop. Cause. — The cause is an inflammation of the uveal tract of the exciting eye. The uveitis may be idio- pathic, but the inflammation most prone to excite l6o LESSONS ON THE EYE. sympathetic trouble is that due to a wound ui the cihary region or the presence of a foreign body in the exciting eve. Other sources of the exciting uveitis are perfo- rating corneal ulcers and intra-ocular tumors. After an enucleation the optic nerve or cihary nerves being caught in the cicatrix ha\'e been known to give rise to sympa- thetic irritation. Sympathetic inflammation may arise at any time from tw^o weeks to many years after the lesion of the exciting eye. Sympathetic irritation may appear sooner. In spite of many theories, our knowl- edge of how this inflammation is conveyed from one eye to the other is yet speculative. It is probable that the condition in the exciting eye is a proliferative uveitis (Fuchs), and that the infection, which is patho- genic for the eye alone, is conveyed through the blood to the sympathizing eye (Romer) . Treatment. — As sympathetic irritation is always cured by enucleating the exciting eye, this should be done at once, but if sympathetic inflammation is estab- lished this procedure will rarely stop it and should not be resorted to if the exciting eye has useful vision, as it will often retain the best vision of the tw^o. If, in sym- pathetic inflammation, the exciting eye is bhnd, enucle- ate it. Its removal may do some good and can do no harm. The patient should be kept in a dark room, hot fomentations used four or five times a day, ano- dynes given for pain, and mercury and tonics given internally. Atropin and dionin should be used as in jilastic iritis. Sahcylate of soda to the limit of tolera- tion has been very successful in some cases. As the treatment of sympathetic inflammation is so unsatis- factory, its prophylaxis becomes doubly im]:)ortant, DISKASKS OI- THK VITRKOUS. l6l therefore it is cuh'isaltle to enueleate all blind eyes affeeted with ehronie irido-eyelitis; all eyes with irido- cyclitis due to the presence of a foreign body, which cannot be removed, even if some vision remains; also all shrunken globes and stumps which are tender on pressure. DISEASES OF THE MTREOUS. MUSC.-E VOLITAXTES. The \-itreous consists of 98.5 per cent, water and 1.5 |)er cent, of a reticulated framework of very fine fibers, within the meshes of whiqh are found connective tissue cells and migratory leucocytes. These normal cells of the vitreous sometimes become so apparent as to cause considerable annoyance. They appear as spots in front of the eye which may assume a great variety of shapes. They are most apparent when the patient looks toward some bright background, such as the blue sky or a sheet of white paper. Vision will be normal and an examina- tion with the ()i)hthalm()SC()]je will reveal no opacities or any other pathologic condition. It is difficult to explain why the shadow of these fixed cells will give more annoy- ance at one time than another. These periods of annoyance seem to depend, in a measure, upon faulty digestion, and patients will often associate them with "biliousne-ss." The treatment consists in correcting any refracti\-e error and any defect in digestion, also impressing the patient with the harmlessness of the con- dition and urging upon him the necessity for disregard- ing the sym])toms. 1 62 LESSONS ON THE EYE. OPACITIES OF THE VITREOUS. Vitreous opacities may appear as fine dust, fiocculi, threads, flakes, large masses, or membranes. If the vit- reous has become fluid (synchysis) the opacities will change their position with every movement of the eye. Symptoms. — The patient will complain of lowered vision, which will be found relatively worse for distance than for near. He will see spots in the field of vision Fig. log. — Opacities of the vitreous, dust-like at the lower pari of the with threads and membranous masses above. (Jackson.) which correspond in size, shape, and position with the opacities which cause them. If the vitreous is fluid, vision will be best when the eye is kept still long enough to allow the opacities to settle. Opacities of the vitreous can only be seen objectively with the ophthalmoscope. Cause. — The opacities are inflammatory exudates or hemorrhages which originate in diseases of the ciliary body, choroid, or retina. The fine dust-like opacities found in the posterior part of the vitreous are due to syphilitic involvement of the retina and choroid. Large black masses are often caused by the choroiditis, which is associated with high degrees of myopia. Gout, DISEASKS OF TIIK VIIKKOUS. 163 tuberculosis, malaria, and senility are considered pre- disposing causes. Treatment. — Small and recent opacities may be cleared up, but if they are large or of long standing there is little prospect of a cure. Diaphoresis induced by pilocarpin injections is advised. Also purging with salines. Dionin is a powerful local lymphagogue and might prove of value. Main reliance is placed in the constitutional treatment and mercury and potassium iodid have proven the best remedies we possess. HEMORRHAGE IXTO THE VITREOUS. Symptoms. — If the hemorrhage is small the result will be a clot in the vitreous amounting to an opacity, the symptoms of which have already been given. Vision will depend upon the amount of blood emptied into the vitreous. If the hemorrhage is pronounced vision will be reduced to the perception of Hght and the light will appear red. At times even light perception is lost. When the vitreous is permeated with blood the diagnostic value of the ophthalmoscope is lost, as every- thing beyond the lens appears black. The iris and cili- ary body may become inflamed and glaucoma is not an infrequent result. Cause. — Rupture of a blood vessel of the ciliary body, choroid, or retina from traumatism or disease. Treatment. — If the hemorrhage seems to be sponta- neous, absolute quiet and the internal administration of such remedies as gallic acid or ergot may be of service. An effort should be made to produce absorption of the clot, to which purpose the treatment for vitreous opaci- 164 LESSONS ON THE EYE. ties is a])])licablc. If the hemorrhage is ])rofuse the prospect is not flattering. Recurring vitreous hemor- rhage is exceedingly dangerous to vision. In a few- cases of recurring hemorrhage in both eyes, bHndness being imminent, the common carotid has been hgated with beneficial results. FOREIGN BODIES IN THE VITREOUS. Foreign bodies, such as splinters of wood, lead shot, small stones, particles of metal, and fragments of glass, may be accidently driven into the vitreous. The wound of entrance may be destructively large or so insignificant that it is hard to find. It is often very difficult to determine positively that a foreign body is present. The X-ray is of great value in such cases. As a general proposition it may be said that the foreign body or the eye must be removed. Particles of iron and steel may be removed by the electro-magnet. A dia- magnetic body must be withdrawn with forceps or carried out with the vitreous which escapes through an incision made as near as possible to the point where the foreign body is lodged. LESSON XXII. DISEASES OF THE CHOROID. The function of the choroid is to nourish the retina and vitreous, and to prevent ;-eflection, by the power to absorb li^^ht possessed by its pigment. In albinos there is almost a total absence of pigment in the uveal tract, and great distress from photophobia is the result. Albinos are, as a rule, afflicted with amblyopia, refract- ive errors, or nystagmus. Dark glasses are often a necessity to these patients. CHOROIDITIS. Choroiditis is either plastic or purulent. The plastic form may be divided into disseminate, central, syphil- itic choroido-retinitis and myopic choroiditis. When purulent choroiditis results in inflammation of all the structures of the eye, and this is its usual termination, it is called panophthalmitis. PLASTIC OR EXUDATIVE CHOROIDITIS. Symptoms. — If the morbid process is limited to the choroid, external signs of inflammation are absent. Visual disturbance will be the only subjective symp- tom. The objective symptoms are revealed by the ophthalmoscope. There may be one or more areas in the field of vision in which objects are seen dimly or not at all. These areas are called scotomata. If vision is only diminished in a scotoma, it is 165 l66 LESSONS ON THE EYE. said to be relative; if it is entirely absent, the scotoma is positive. Vision may be reduced by a diffuse cloudiness of the vitreous, or if opacities have formed in it there may be movable dark spots in the field. Night blindness is a frequent symptom (page 2x4). Patients may complain of sparks or lights before their eyes. There may also be distortion of the outline of objects called metamorphopsia. For example, in metamorphopsia a series of parallel lines will appear wavy in places, or when reading, a word in a line will appear above or below its normal position. If the choroidal exudate causes a separation of the percipient elements of the retina objects will appear unnaturally small, a condition called micropsia. Megalopsia, a condition in which objects look unnaturally large, is produced by shrinkage of the exudate. If the in- flammatory process is limited to the periphery of the choroid there may be no subjective symptoms whatever. The visual disturbance will depend upon the prox- imity of the inflamed area to the macula and the amount of involvement of the vitreous. The ophthalmoscope will show, in recent cases, ill- defined yellowish patches under the retinal vessels. These spots of exudation may absorb and leave no sign, but generally the choroid at these points atrophies and the sclera shows glistening white through it. Around the borders of these atrophic areas, pigment is soon deposited. The retina over the inflamed area is usually invoU^ed and also partakes of the subsequent atrophy, which explains the scotomata or blind spots in the field of vision. The inflammatory process may extend to the vitreous and cause a cloudiness of that DISEASES OF THE CHOROID. 1 67 ImkIv, at times SO (k-nse as to prcx-enl an oj)luhalnio- scopic view of the underlying tissues. Cause. — Syphilis, malnutrition, serofnla, infection, anemia, a blow upon the eyeball, high myopia, and in some cases no cause can be assigned with any degree of accuracy. The choroid, being a part of the uveal tract, is subject to inflammation arising in the iris and ciliary body. Treatment. — Absolute rest of eyes and the use of mydriatics, smoked glasses, mercury, iodid of potas- sium, and tonics. Fig. 1 10. — Choroiditis disseminata. The macular region not being involved, central vision n^ight be nornril. (After De Wecker.) Disseminate choroiditis is the form inflammation of the choroid is most likely to assume. As the name indi- cates, there is a general involvement of the choroid. There will be a number of areas of exudation or atrophy, depending upon the stage of the disease, scattered over the fundus. As long as the macular region is t68 lessons on the eye. not involved, central N'ision may remain good. There- fore disseminate choroiditis may be far advanced be- fore the patient is conscious of any eye trouble. Its course is chronic. Treatment may check the disease, but cannot restore the function of the atrophic areas. Central choroiditis involves the macular region. It may consist of one large inflammatory area or several Fig. III. — Central chon>i(litis. (\\'ccl C i i 5 c 1 s s 1 "5 1 •2 1 s 1 1 1-^ 1 .ii o (JC 1 1 ° c 3 1 •r; o K a B « 3 -0 c 1 .s M . 3 be a, a C •S 2 ■r- C < 1 s II o 1 s > II : > : 2 c 1^ 2 ti IS •a L°. " • M 1 ^ . . •c a r > >^ -- •-• 1 2 J 1 1 1 z 1^ o ■ ^o^.i " " >." t •£ ; ■ •2 i ^ ^ II 11 m 1 i^ ■o H H 1 1 1 c Z 1 2 11 ill 1 ^ ji O < l-H Q ■5 1 1 ^o _ 1 E c 6 £ 1 p. o c' •z 2 z z z < a; o 3 a) : S J 1 a a i S 3 .2 1 ; 1 c 1 O. 2 i. ■o -. "c 1 s F « V 1 u o t* , D H f- -■ H t -" c :> " LESSON XXIV. DISEASES OF THE CRYSTALLINE LENS. DISLOCATION OF THE LENS. This condition may exist congenitally or may be due to accident or disease. The lens may be partially held by the suspensory ligament or may be totally detached. The dislocation may be to the side, back into the vitre- ous or forward, through the pupil, into the anterior chamber. If due to disease, it is associated with cho- FiG. 119. — Downward dislocation of a cataractous lens. roiditis, cyclitis, and a fluid state of the vitreous. The lens may be perfectly transparent or cataractous. If cataractous the malposition may be easily detected (Fig. 119). If transparent and not in the anterior chamber, the ophthalmoscope will re\'eal the condition. A transparent lens in the anterior chamber can be diag- nosed by close inspection with the unaided eye. Con- 184 DISEASES OK THE CRYS TAELINE LENS. T8:; i^cnilal partial disloc-alioii may l)c let alone. W'Ikmi (hie to accident or disease it would 1 letter be remo\'ed. Opacity of the lens, or its capsule, or both, constitutes cataract. Numerous terms, which explain themselves, are used in classifying cataracts, such as lenticular,* cap- sular, and capsulo-lenticular; partial and complete; traumatic and spontaneous; fluid, soft, and hard;con- FiG. 120. — .\, normal lens; P., anterior juilar cataract ; C, posterior polar cataract; D, cortical cataract; E, nuclear cataract; V, lamellar cataract. (Juler.) genital, juvenile, and senile; immature, mature, and hypermature; .simple and comphcated ; stationary and progressive; gray, white, amber, and black. Cataracts are further classified by terms which indi- cate the location of the opacity as follows : I. Anterior polar cataract, in which the opacity is a small spot in the center of the anterior capsule, extend- ing into the subjacent lens substance. It is usually pyramidal in shape, and may be congenital or acquired in early infant life. When congenital it is supposed to be the result of a fetal inflammation in which a deposit 1 86 LESSONS ON THE EYE. of h'mi)h was left on the anterior capsule; or to be due to the adherence of the fetal ])upillary membrane to the capsule. When acquired it is due to a perforation of the cornea which has allowed the lens to come foru'ard in contact with the cornea. 2. Posterior polar cataract, similar to the preceding, except located in the center of the posterior capsule. In fetal Ufa the hyaloid artery comes in contact with the lens at the posterior pole. An incomplete clearing up of the point of contact would explain a congenital pos- it v. Fig. 121. — Nuclear cataract, i, Section of lens; central position of opat 2, appearance by ophthalmoscope; appearance by oblique illuminatior terior polar cataract. Another form of opacity, gener- ally called posterior polar, but which in reality lies in the posterior cortex, assumes the shape of a star or rosette ; the center of the star corresponding to the pos- terior pole of the lens. It is usually associated ^yith retinal or choroidal disease. 3. Lamellar or zonular cataract, in whch the opacity is confined to one or more of the layers of the lens. It is assumed that there is a disturbance of nutrition at a period of fetal Hfe subsequent to the development of the clear nucleus. The layer of lens substance developed at the time of the nutritive disturbance is opaque. The interruption to the normal development of lens matter being temporary, the subsequent la\-ers are transparent. DISEASES OF THE CRYSTALLINE LENS. 1 87 4. Nuclear cataract, in which the opacity begins in the hard center of I he Umis. 5. Cortical cataract, in which the oi)acity bci^ins at the periphery of the lens. Symptoms. — In children, if the cataract is complete, it is easily diagnosed, as the pupillary area will be white or gray and the eye will be blind. If the cataract is zonular, which is the most frequent form in children, and is always congenital or arises in early infant life, the vision is much reduced, the child beha^•ing as if near- FiG. 122.— Cortical cataract, i, Section of lens; opacities beneath the capsule; 2, Opacities as seen by the ophthalmoscope; 3, Opacities as seen by oblique illumination. sighted. Best vision is secured when the pupil is di- lated, as the patient can then see around the opacity. Hence these children w411 shade their eyes or turn their backs to the light to get better vision, and will find their sight improved by the twilight or cloudy weather. Close inspection, with the pupil dilated, will reveal a pale, round, central opacity of the lens; the rim of the opacity being denser than the center, that will distin- guish it from a nuclear cataract which is denser in the center. It is often found that children with zonular cataracts have been subject to infantile convulsions or are affected wdth rachitis. Anterior polar cataract is easily detected by the small, snow-white speck seen in the pupillary area. It does not affect vision as much as the zonular variety. The great majority of cataracts 1 88 LESSONS ON 'J-HE EYE. arise after the forty- fifth year and are caUed senile or hard . The latter term is derixed from the condition of the nucleus, which at this age has become quite dense. They are usually nuclear or cortical. As a rule, the first symp- tom noticed is failing vision, not improved by glasses. In some cases, in the first stages of the disease, the opac- ity increases the index of refraction of the lens, and thus increases its refractive power sufficiently to enable the patient to read without glasses. The patient rejoices in what is commonly called second sight. Unfortunately, this state is temporary and gradual loss of vision follows. If the cataract is nuclear, vision is improved by any circumstance which dilates the pupil. There is gener- allv some hvperemia of the conjunctiva, lacrymation and itching. Sometimes inspection of the pupil reveals no anomaly, but cataract, in the advanced stages, shows a distinct white or grayish appearance of the pupillary area. Oblique focal illumination will demonstrate some opacities, but to determine their presence in doubtful cases the ophthalmoscope must be used. With the pupil dilated the whole lens can be brought under inspection and the slightest opacity will be detected by the ophthalmoscope. The time between incipiency and maturity varies greatly in different cases, and in a few a partial opacity will remain stationary for the rest of life. A traumatic cataract, due to rupture of the capsule, may swell so rapidly from imbibition of aqueous humor as to bring on glaucomatous symptoms. A cataract is said to be ripe when all the lens substance is opaque. This may be determined by throwing a light, obliquely, into the dilated pupil. If there is a dark, crescent-shaped shadow on the lens, next to the DISEASES OF THE CRYSTALLINE LENS. 1 8g iris, on the same side as the Hght, there is eonsiderable lens substanee whieh is still transparent. If the entire lens is opaque, no shadow will l)e east ujion it by the margin of the iris. Cause. — Cataract is supposed to be due to some dis- turbance of the nutrition of the lens. It is a degenera- tive change, coming as do gray hairs, \'ery little being known of the conditions that conduce to it. Diabetes, ergotism, heredity, glaucoma, hyperopia, and spasms in children are supposed to be etiological factors. Glass blowers, stokers, etc., whose eyes are exposed to excess- ive heat and light, are supposed to be unusually sub- ject to the disease. Traumatic cataracts are due to some accident which jjunctures the capsule or loosens the lens from its ligamentous attachment. Treatment. — Spontaneous absorption of the cataract has been reported in a few authenticated cases, but no therapeutic agent has yet been discovered that will bring about this happy result. The treatment is sur- gical. For the operations suited to the different varie- ties consult a text-book. Before operating or recom- mending a case for operation be sure to test the bad eye for other pathologic conditions. Cataract prevents the distinction of objects, but does not obstruct light. Take the patient into a darkened room and with the good eye well covered see if he can point out the direc- tion of a lighted candle when held in all parts of the field of vision. If he can readily follow the light his retina and optic nerve are healthy and a successful operation will make him see again. If he cannot see the light at all an operation is useless. If he sees only in certain parts of the field or detects slowly the diff'er- igo LESSONS ON THE EYE. ence between light and shadow, an operation will be proportionately meager of results. An aphakic eye is one which has no lens. The re- moval of the crystalline lens from an emmetropic eye will make it very hyperopic. After a cataract operation upon an emmetropic eye a strong convex lens must be Fig. 123. — Speculum used to hold the lids open in operations upon the eyeball. worn to compensate for the one removed. If the oper- ated eye was previously hyperopic the correcting lens will be stronger still ; if it was m^^opic the correcting lens will be weaker than in the case of an emmetropic eye. It is possible for the removal of the lens to so neutralize a high degree of myopia as to secure excellent vision without the help of glasses (page 55). LESSON XXV. DISEASES OF THE RETINA. HYPEREMIA AND ANEMIA. The retinal vessels do not participate much in the changes of the intra-cranial circulation. There is some retinal congestion in meningitis and always venous engorgement in papillitis and thrombosis of a retinal vein. The same condition of the veins, in milder form, is often met with in emphysema and in weakness of the heart's action. Slight hyperemia of the retina and disc are sometimes associated with the strain of an uncorrected refractive error, but these mild hypere- mias are difficult of diagnosis owing to the variations in the appearance of the fundus, found in health. Anemia of the retina may result from embolism of the central artery, great loss of blood, cholera, spasm of the arterial coats due to toxic doses of quinin and from spasm due to vaso-motor disturbance. The dimness of vision found in some cases of migraine or "blind headaches" are examples of the latter condition. RETINAL CHANGE FROM DIRECT SUN RAYS; SNOW BLIND- NESS; ELECTRIC OPHTHALMIA. Persons who have looked directly at the sun have sometimes complained afterward of central scotoma. These blind spots vary in their severity and persistency, sometimes being ])ermanent. There may be central 191 192 LESSONS ON THE EYE. defect for colors and also metamorphopsia. The ophthalmoscope will often show a minute lesion near the macula. The treatment consists of rest of eyes, dark glasses, and hypodermatic injections of strychnin. As a rule, the only result, if any, of exposing the eyes to the glare of the snow is a mild form of conjunctivitis, but sometimes there is temporary, and, in rare in- stances, permanent amblyopia. Exposure of the eyes to strong electric light, as in electric welding, may result in severe changes, such as are found in injury by direct sunlight, and may take a mild form of ophthalmia, such as is occasioned by exposure to snow. Electric workers now^ prevent these conditions by using glasses deeply colored with yellow, ruby, or a combination of deep blue and red. EMBOLISM AND THROMBOSLS OF RETINAL VESSELS. Syniptoiiis of Eiubolisni. — Sudden loss of vision, par- tial if the obstruction lodges in a branch artery, total if it stops in the main trunk. The blood vessels will be much reduced in size. The retina will be white and opaque, the greatest opacity lying in the region around the macula and disc. The macula will appear as a cherry-red spot, owing to the fact that it is much thinner than the rest of the retina, and the choroid shows through it. Degeneration of the retina occurs in a few days, soon followed by atrophy. The optic nerx'c gene- rally atrophies. Vision is rarely restored. Cause. — The plug may come from vegetations in the heart, due to valvular disease or endocarditis. It may DISEASES OF THE RETINA. 193 also result from aneurism of the aorta or from atheroma of the arteries. It also occurs with Bright's disease and pregnancy. Symptoms of Tromhosis. — The extent of visual loss depends upon the location of the thrombus, in the cen- tral vein or one of its branches. Vision is, as a rule. Fig. 124, — Embolism of the central artery of the retina. (Jennings.) not lost as suddenly as in embolism. There will be edema of the disc, tortuosity and engorgement of the veins, and numerous hemorrhages in the area drained by the thrombotic vein. Cases do not always present the definite appearance here described. The arterial circulation may be obstructed by endarteritis and throm- bosis. Closure of one set of retinal vessels will produce disturbance in the other, so that the clinical picture made be a composite of the two conditions. Cause. — Retarded venous circulation of the old, the 194 LESSONS ON THE EYE. emphysematous or those suffering from cardiac lesions. It may also be due to phlebitis. Treatment of embohsm and thrombosis is of little avail. An attempt may be made to absorb the ob- struction by using iodid of potassium. Digital massage of the ball has been recommended for recent embolism. Fig. 125. — Thrombosis of the retinal veins. (Jennings.) RETINITIS. Inflammation of the retina may be limited to this membrane or may be associated with inflammation of the optic nerve (neuro-retinitis) or choroid (choroido- retinitis). The disc is usually involved unless the retinitis is ^'ery mild, and some opacity of the vitreous often co-exists. Owing to the fact that the disease is generally constitutional in origin, we find it almost always bilateral. Normally the retina is a transparent DISEASES OF THE RETINA. 1 95 membrane, but when inflamed it appears smoky or hazy and, at times, to such an extent as to obscure its vessels in some part of their course. The veins may appear unusually large and tortuous and frequently there are hemorrhages. Often there will appear dis- tinct white spots arranged along the course of the ves- (Mcycr.) sels or around the macula or disc. These spots can be differentiated from choroidal atrophy by the absence of the pigmented border and the softness of their out- line. In retinitis there will be dimness of vision in all degrees. There may be limitation of the field of vision and perhaps scotomata. Micropsia (objects appearing unnaturally small), megalopsia (objects unnaturally large), metamorphopsia (unnatural position of objects [96 LESSONS ON THE EYE. in the field, straight Hnes appearing wavy, etc.) and night blindness are forms of visual disturbance which may be manifested. There may be photophobia, but there will be no pain and no external evidence of inflam- mation. Recovery may take place with little or no loss of vision, but generally the prognosis is grave. The result depends largely upon the cause of the attack and the region of the retina involved. Different forms Fig. 127. — Recent severe retinitis in renal disease. (Govvers.) of the disease are named according to etiology, leu- kemic, albuminuric, diabetic, gouty, and syphihtic. There are other forms named from characteristic fea- tures, such as simple, hemorrhagic, and purulent retinitis. Many forms of retinitis have been described as distinct pathologic conditions, w^hen they are probably varying pictures of an identical pathologic process. The purpose of this book restricts it to a general descrip- DISEASES OF THE RETINA. 1 97 tion of retinitis and a differentiation of its commoner types. Albuminuric retinitis occurs in about 7 per cent, of all forms of albuminuria. It appears late in the stage of the renal trouble, the majority of patients dying within two years after its advent. Both eyes are generally affected. The characteristic feature is the presence of the white spots of fatty degeneration Fig. 128. — -Renal retinitis at a late stage. (Wecker and Jaeger.) which tend to arrange themselves in a stellate figure around the macula. Complete recovery from albumin- uric retinitis has been observed. Diabetic retinitis presents the same general sympto- matic picture as albuminuric retinitis. If there is any difference it is that the white degenerated spots are more diffuse and have not the same tendency to a stel- 190 LESSONS ON THE EYE. late formation around the macula in diabetic retinitis. Hemorrhages are also more numerous in the latter form. Often the differentiation will depend upon the urinary analysis. Syphilitic retinitis occurs from congenital as well as acquired syphilis. It is, as a rule, associated with choroiditis and opacity of the vitreous. Night blind- ness is a prominent symptom. The general characteris- tics are those already described. If the white spots of fatty degeneration are present they are numerous, very small and scattered rather than arranged around the macula. The latter arrangement being almost pathog- nomonic of renal disease. See Syphilitic Choroido- retinitis, page 168. Hemorrhagic retinitis, as the name implies, is an inflammation of that tissue in which hemorrhages are the most prominent feature. These flame-like extravasations may be scattered over the whole fundus. The optic disc is usually edematous, the veins tortuous and enlarged. Vision depends largely upon the loca- tion of the hemorrhagic spots in relation to the macula. The disease appears after middle life and in those suffer- ing from disease of the heart or of the vessel walls. The ophthalmoscopic picture is practically identical with that of thrombosis of the retinal vein and dif- ferentiation may be impossible. Cause. — Generally one of the constitutional condi- tions enumerated above is responsible for the disease. The etiology of simple idiopathic retinitis is obscure. Treatment. — Demand absolute rest of the eyes. Subdue the light by the use of smoked glasses. Treat the constitution as indicated by each case. DISEASES OF THE RETINA. 199 RETINITIS PIGMENTOSA. This is a degenerative rather than an inflammatory condition. It is extremely chronic in its course, some times requiring years to reach its usual termination in blindness. Vision is much affected, but the symptom most complained of is night blindness. The field of vision gradually contracts until only central vision is Fig. 129. — Pigmentary degeneration of the retina. (Jaeger.) left. This much may remain for years. The fundus shows a peculiar stellate pigmentation beginning at its periphery and extending gradually to the macula. The amount of pigment is no measure of the gravity of the case. The caUber of the retinal vessels dimin- ishes and there is slow atrophy of the retina and disc, with occasional opacity of the posterior lens capsule. The -cause is obscure, but consanguinity of parents seems to be an etiological factor. No treatment is LESSONS ON THE EYE. successful. Galvanism, subconjunctival injections of salt solution and strychnin have been recommended. DETACHMENT OF THE RETINA. This condition consists in a separation of the retina from the choroid, the intervening space being occupied Fig. 130. — Ophthalmoscopic appearance of detached retina (erect image). (After Wecker and Jaeger.) by a serous fluid, blood, or a tumor. Vision is affected in proportion to the extent and location of the detach- ment, the field showing a defect corresponding to the position of the lesion. The ophthalmoscope reveals a Fig. il detachment of retina. (Nettleship.) [31. — Section of eye with parti steel-gray reflex from the detached part, over which the retinal vessels flow. The presence of the vessels distinguishes this from any other condition presenting a similar reflex. If the detachment be recent there will be partial loss of vision, which increases with the degen- DISEASES OF THE RETINA. 20I eration of the retina. The retina rarely returns to its normal condition. The size of the detachment may re- main stationary or may extend over the entire fundus. Cause. — Blows upon the ball or jars by transmitted force. Tumors of the choroid. Disease resulting in fluidity or shrinkage of the vitreous. High degrees of myopia. Treatment. — Long-continued rest in bed with eye bandaged. Evacuation of the subretinal fluid by a knife, needle, or pointed cautery ; or absorption of it by pilocarpine sweats and abstinence from fluids. Sub- conjunctival injections of salt solution. The results of treatment are discouraging. GLIOMA OF THE RETINA. This very malignant tumor is either congenital or appears in childhood. The first symptom noticed is a 202 LESSONS ON THE EYE. yellow reflex from the pupil. Tests will prove the eye to be blind. It is difficult to differentiate from pseudo- glioma in this stage (page 171). Owing to the great rapidity of the tumor's growth the diagnosis can soon be made. Active inflammation, increased tension, and pain soon develop with glioma; whereas in pseudo- glioma there is no pain and the tendency is toward diminished tension and shrinkage of the ball. In a few months the tumor fills the eyeball and with its con- tinued growth protrudes between the lids, fills the orbit, and extends to the brain. Distant organs may become affected. If the eyeball is removed when the tumor is confined within it, there is some hope for the patient. When in doubt as to the diagnosis, enucleate, as no harm is done if the case proves to be pseudo-glioma. LESSON XXVI. DISEASES OF THE OPTIC NERVE. Optic neuritis, or inflammation of the optic nerve, may be divided into two kinds :— . 1. Papillitis, which involves the intra-ocular end of the nerve. 2. Retro-bulbar neuritis, which affects the nerve between the ball and the chiasm. PAPILLITIS. The optic disc or papilla is the intra-ocular termina- tion of the nerve or that part between the lamina cri- brosa and the retina. With the opthalmoscope the nor- mal disc appears as a white, circular area in the orange colored groundwork of the choroid. The white reflex of the disc is caused by the lamina cribrosa showing through the transparent nerve fibers. In inflamma- tion of the disc there are no definite subjective signs. There is usually contraction of the field of vision and derangement of color perception, but vision may not be reduced until late in the progress of the disease. Main rehance in diagnosis is placed on the ophthalmo- scope, which shows a serous infiltration of the disc manifested by redness, sweUing, and loss of its outline. The retinal arteries appear small and the veins filled and tortuous. The strangulation of the veins some- times results in hemorrhages in the retina. In the 203 204 LESSONS ON THE EYE. great majority of cases both nerves are inflamed. If the inflammation extend by continuity of tissue to the retina, the condition is called neuro-retinitis. Papillitis may sometimes result in complete recovery, but in the majority of cases a partial or total atrophy of the nerve results. Cause. — If monolateral it is generally the result of some orbital lesion. When bilateral it is usually due to intracranial disease, most frequently to tumors, but it may be due to meningitis, abscess, depressed fracture or softening. It may also be the result of albuminuria, diabetes, syphilis, lead poison, and anemia. The prognosis will depend largely upon the etiology. Treatment. — Forbid use of eyes. Direct your efforts to the cause, and when in doubt give iodid of potassium, and build up the constitution by the usual methods. RETRO-BULBAR NEURITIS. This condition is also called central amblyopia and toxic amblyopia. Symptoms. — Loss of acute vision, the patient com- plaining of a mist before the eyes. There will be cen- tral scotoma for red and green, and in advanced cases, central scotoma for objects. The affection is nearly always bilateral and the vision of the two eyes nearly the same except in those cases due to morbid conditions of the nose which are more frequently unilateral. There is no contraction of the field, which aids in the differentiation from progressive atrophy. In pronounced cases, the disc shows an unnatural whiteness of its temporal side, and in an advanced DISEASES OF THE OPTIC NERVE. 205 state the whole disc may present the appearance of atrophy. There is proHferation of connective tissue in the nerve and atrophy of those fibers which go to the macula. The progress of the disease is slow, and the chance of recovery good unless of too long standing. It is almost exclusively a disease of men. Cause. — It is due, in the great majority of cases, to the excessive use of tobacco or alcohol. Many obser- g^j^^^jj; -r-iii] Fig. 133. — Ophthalmoscoj.il \ii .\ ..[ ilic .lisc in optic neuritis. The out- line of the disc is clouded. The retinal arteries are contracted, the retinal veins are dilated and tortuous and both are hazy in places. (Fuchs.) vers consider tobacco the most potent etiological factor, and some entirely acquit alcohol of any responsibility for the disease. Alcoholic extract of Jamaica ginger, essence of peppermint, etc., are very popular in some prohibition regions and a number of serious cases of amblyopia have been reported from their use. The methyl alcohol which they contain is considered the toxic agent. Exposure to cold, diabetes, rheumatism, 206 LESSONS ON THE EYE. syphilis, and poison by some chemicals, among which are iodoform and bisulfid of carbon, are supposed to be causative ; and there are also some cases in which no cause can be discovered. Many cases have been re- ported lately which locate the cause in suppuration of the nasal sinuses adjoining the orbit. Whenever in doubt the nose should be carefully explored. longitudinal section (Fuchs.) Treatment. — Absolute abstinence from the offending poison." When not contra-indicated elimination of the poison by purgatives or sweats is advisable. Watch the patient's digestion and give iodid of potassium or strychnin. When due to a constitutional disease, treatment should be directed to the cause. If due to intra-nasal disease the services of a skilled rhinologist will be required. QUININ AMBLYOPIA. Overdoses of quinin cause another' form of toxic amblyopia in which the symptoms are so dift'erent from those just enumerated as to merit a separate description. Symptoms. — The general symptoms of cinchonism will precede the loss of vision. The amount of visual DISEASES OF THE OPTIC NERVE. 207 disturbance varies from a blurring of objects to absence of light perception. The pupils may be widely dilated and the ophthalmoscope reveal a picture similar in some respects to that presented by embohsm of the central artery. When there is sufficient vision to make a test possible, the field will be found contracted and color perception lost. After a variable period vision is de- FlG. -Optic neuritis with hydrops of the optic nerve sheaths Pagenstecher and Genth.) (Afler cidedly improved though it rarely returns entirely to the normal. Salicylate of sodium and acetanilid can also produce a similar amblyopia. Cause. — The action of the drug on the vaso-motor centers is supposed to be such as to cause a violent con- striction of the blood vessels. An anemia of the retina is the result. Treatment. — Use of the offending drug should be dis- continued at once. Inhalations of nitrite of amyl may be tried. Strychnin should be given until constitutional effect is felt. Absolute rest of the eyes must be enforced and general health promoted in every way. 208 LESSONS ON THE EYE. ATROPHY OF THE OPTIC NERVE. In atrophy the medullary part of the fibers is dis- placed by granular fat and connective tissue, with thick- ening of the walls of the vessels and narrowing of their calibre. Symptoms. — There is no pain and no change in the appearance of the ball, unless total blindness exists, 36. — Atropic excavation of the disc. when the pupils will be dilated. Great variety is mani- fested in the visual defects. The loss of vision may be rapid but is generally very gradual and slow. Central vision is lowered and the field contracted, sometimes con- centrically, sometimes irregularly. Color sense becomes defective or lost, perception of green, red, and blue usu- ally disappearing in the order named. If the atrophy be associated with spinal cord lesions we shall, as a rule, find the Argyll-Robertson pupil. The disc will appear abnormally white or gray, slight excavation due to DISEASES OF THE OPTIC NERVE. 209 shrinkage of its substance may be noticed and the retinal vessels will be reduced in size. Cause. — Spinal diseases of which tabes dorsalis is the most important, papillitis, pressure of tumors, disease of the orbit, suppuration in the nasal sinuses, throm- bosis and embolism of the retinal vessels, glaucoma, meningitis, syphiHs, alcoholism, and anemia from great loss of blood may cause atrophy of the optic nerve. It may appear as a purely local disease independent of any other lesion. Treatment. — Correct any derangement of general function. Attack vigorously any suppuration in the accessory nasal sinuses. The galvanic current, one pole over the eye and the other at the back of the neck, is of doubtful utility. Give iodid of potassium, mercury or strychnin to the point of tolerance. Strychnin is more efficacious when given hypodermatically. Anti- pyrin, seven and a half grains every other day, hypoder- matically is also recommended. Treatment is usually ineffectual. LESSON XXVII. FUNCTIONAL DISORDERS OF VISION, ETC. AMBLYOPIA AND AMAUROSIS. These are terms used to express a diminution or loss of vision without any apparent lesion. The two words are used, more or less indiscriminately, but amaurosis is generally applied to the graver conditions. There are many forms of lowered vision, the pathology of which is known, but they do not come under this head. The cause of functional amblyopia may be known, but the exact way in which the loss of vision is produced is unexplained. 1. Traumatism to the head, direct or indirect, or a blow upon the eye, may be followed by amblyopia, more or less persistent. In these cases it is presumed that there is some invisible lesion of the parts concerned in vision. 2. Loss of blood may produce amblyopia, which probably is due to the fact that the retina is affected by the general lack of nutrition. But we do not know why the degree of amblyopia is not always commensurate with the amount of blood lost or why there is greater tendency to amblyopia from hemorrhages of the stomach, uterus, and bowels than from traumatic hemorrhages. 3. Congenital amblyopia generally affects but one eye. It has been mentioned as a factor in the produc- 210 FUNCTIONAL DISORDERS OF VISION, ETC. 211 tion of comitant strabismus. It is supposed to be due to an arrest of development of the eye in fetal or early infant life. Lowered visual acuity is often associated with pronounced errors of refraction, espe- cially astigmatism. If accurately corrected at an early age the eye may gradually develop normal acuteness of vision. 4. Hysterical amblyopia may occur in both sexes but is most frcciucnt in females. As might be supposed the symptoms assume a great variety of forms, such as total blindness, hemianopsia, scotoma, color blindness, and contraction of the visual field. Neurasthenic school children, especially girls, are frequently thus afflicted and great tact and judgment are required in their treatment. 5. Simulated amblyopia, or malingering, may be due to a desire to exaggerate an injury over which a lawsuit is pending, to secure a pension, to escape some disagree- able duty or to excite sympathy. For obvious reasons, but one eye is claimed to be affected. Numerous tests will reveal the patient's hypocrisy, if he claims blindness in but one eye, among which are the following : — 1. Put on him a pair of spectacles, one lens of which is plain glass and the other a prism with its base up or down. If malingering he will see double and an effort to walk, especially to go down stairs, will be made so cautiously that his true condition is detected. 2. Place before the eye he claims is bad a plain glass and before the other a plus glass just strong enough to obscure its vision. If with these vision is normal, the patient is malingering. 3. Hang some green letters in front of a black back- 212 LESSONS ON THE EYE. ground, at a convenient distance. Hold before the good eye a glass colored red. If he reads the letters, he does it with his bad eye, as the green letters cannot be seen through the red glass. Red letters on a white background are much obscured when seen through a red glass. 4. Put a drop or two of atropin in the good eye and to allay suspicion an equal number of drops of cocain may be put in the bad eye. When time enough has elapsed for the atropin to paralyze accommodation, hand the patient a book. If he reads it he does so with the eye he claims to be amblyopic. If the patient claims to be bUnd in both eyes his detection is more difficult and a close watch may be necessary to determine the true condition. A simple test, which may be of service, is to ask the patient to look at his own hand. A blind man will turn the eye- balls toward the hand, a malingerer may intentionally look in some other direction. AMAUROSIS PARTIALIS FUGAX. This condition, which is also known as scintillating scotoma is a very common form of temporary disturb- ance of vision. It may not be recognized owing to the unsatisfactory description of his symptoms given by the patient. A sudden blurring of the vision is noticed, which for a period of five minutes gradually gets worse. Reading is then almost impossible and distinct objects have a veiled and confused outline. There is a very uncomfortable flickering or glimmering appearance in the field of vision. The sensation is likened to that FUNCTIONAL DISORDERS OF VISION, ETC. 213 presented by the atmosphere which rises over a red hot stove. There may be flashes Hke zig-zag Hghtning circling around the periphery of the field, and homony- mous hemianopsia may be present. The uncomfortable sensation is not dispelled by closing the eyes. In about thirty minutes the symptoms disappear and are followed in the majority of cases by a frontal headache. The attacks vary in frequency from one in a life time to several a day. It is supposed to be due to a circulatory disturbance in the brain cortex. Patients will attribute it to an indefinite variety of causes. Treatment con- sists in improving the general condition of the patient. Validol in 20-drop doses has been recommended. HEMIANOPSIA. Hemianopsia is a term used to express diminution or total loss of vision in one-half of the field. Both eyes are usually affected, which indicates a lesion in or back of the chiasm. If only one eye is affected the lesion is probably in front of the chiasm. In the great majority of cases of hemianopsia affecting both eyes the diminu- tion or loss of vision will be in the right half of each field or the left half of each field. This is called homonymous hemianopsia. We may have loss of the external half of each field called bitemporal hemianop- sia, or of the internal half of each field called binasal hemianopsia, but these conditions are rare. A condi- tion still more uncommon is loss of the upper or- lower field. The lesion which causes hemianopsia may lie at any part of the visual tract from the eyeball to the cor- tex of the brain and a knowledge of the origin and dis- 214 LESSONS ON THE EYE. tribution of the optic nerve fibers is necessary to determine its location. The lesion may be a tumor, periostitis, blood clot, softening of the brain, atheroma of adjacent vessels, injuries, etc. Treatment must be directed to the cause. Fig. 137. — Lesion at A, A, would cause right hf)monymous hemianopsia. B, B, would cause left homonymous hemianopsia. C, C, would cause bitem- poral hemianopsia. D, D, would cause binasal hemianopsia. NIGHT BLINDNESS. Most authors use the word hemeralopia to express night blindness and nyctalopia to express day blindness. Greenhill has proven that they are in error and that the reverse is correct according to derivation and ancient usage. The night blindness of retinitis pigmentosa must not be confounded with the functional variety being described in which there are no visible lesions of the fundus. In functional night blindness vision may be normal in a bright light but is greatly lowered on dull days, in the twilight or in dimly lighted rooms. It is FUNCTIONAL DISORDERS OF VISION, ETC. 215 found in persons who have been exposed to glaring Hght, such as travelers in the tropics, glass blowers, electric welders and those who work before furnaces. It is also supposed to be associated with certain states of lowered vitality such as scorbutus, starvation, etc. The treatment consists in protection of the eyes by dark glasses, the use of tonics of quinin, iron, strychnin Fig. 138. — The right and left field of vision in homonymous hemianopsia, resulting from unilateral cerebral hemorrhage. The darkened areas indicate the obliterations. The normal areas remaining are contracted. and cod Hver oil, and changing the occupation if that seems at fault. Mallannah says decreased alkalinity of the blood is the cause of night blindness and recom- mends the use of urotropin. DAY BLINDNESS. This condition is the opposite to night blindness in that the patient sees better and greatly prefers dimin- ished illumination. It is found as a symptom in retro- bulbar neuritis, albinism, dilation of the pupil from third nerve paralysis or from the use of a mydriatic, cen- tral cataract, etc. It also exists as a functional con- dition independent of any demonstrable lesion. Func- 2l6 LESSONS ON THE EYE. tional day blindness is found in persons who have been excluded from the light for a long period and is also a frequent symptom of hysteria. When day blindness is a symptom, the primary affec- tion should be treated. If it is functional examine closely for muscular insufficiency and errors of refrac- tion ; build up the constitution and accustom the eyes to light by resorting to the strategy demanded by each case. LESSON XXVIII. GENERAL THERAPEUTICS. THE APPLICATION OF HEAT AND COLD. Heat is of great service in relieving pain in and around the eye. Dry heat is best apphed by means of a Japa- nese box. This is a small tin case which can be kept hot for several hours by means of a burning cartridge of punk. Flannel cloths, heated before a fire or in an oven, are efficacious, but require frequent changing. Moist heat is secured by cloths wrung out of very hot water. They should be changed often enough to main- tain an equable temperature. Another w^ay of applying moist heat is to fill a tumbler to the brim with hot water and then place the eye, with the lids closed, as far in it as possible. Moist heat by stimulating the circiilation promotes resolution, as, for example, in ulceration of the cornea. It hastens the suppurative process as in phlegmon of the lid. It is applicable to all deep-seated inflammations, such as iritis and glaucoma. Heat is usually applied for fifteen to thirty minutes at a time, three or four times a day. Cold is of service in restraining the inflammatory proc- ess after traumatisms and in reducing the congestion of conjunctival inflammations. Muslin squares may be placed on a block of ice and transferred to the eye with sufficient frequency to maintain the desired tem- perature. The desired effect may also be secured by 217 2l8 LESSONS ON THE EYE. wringing the cloths out of cold water and changing them frequently. The cold application on page io6 is very grateful. ANESTHETICS. General anesthesia should be used on unruly patients, in plastic operations, enucleations, advancements of the muscles and w^hen there is so much inflammation that local anesthetics are ineffective. Local anesthesia will suffice for the majority of eye operations. The removal of chalazions and other lid operations are not rendered painless by the instillation of a local anesthetic. It must be injected into the tissues and this is often impracticable ow4ng to the change produced in the relationship of the parts. Cocain hydrochlorate is used in two to four per cent, solutions. If greater strength is needed its toxic prop- erties must not be forgotten. The indiscriminate use of cocain in the treatment of eye diseases is to be deplored. It is questionable if it serves a good purpose in any other role except that of an anesthetic. There is no doubt of its ability to do harm under certain conditions. It causes a drying out and exfoliation of the epithelial layer of the cornea. To prevent this the patient may keep the lids closed between instillations" and in opera- tions some bland aseptic solution may be dropped on the cornea at proper intervals. Cocain also reduces the intra-ocular tension, constricts the small blood \'essels and dilates the pupil . For the removal of foreign bodies from the cornea, one drop is often all that is necessary. A second drop a minute later will quite suffice. For the formidable operations more instillations are required. GENERAL THERAPEUTICS. 219 Cocain spoils quickly and old solutions should not be used. Holocain hydrochlorate is used in a one per cent, solution. It causes slight pain when first dropped in the eye. It does not reduce congestion or lessen hemor- rhage by constricting the blood vessels as does cocain. Its advantages over cocain are that it does not dilate the pupil, causes no drying of the cornea, will not spoil in solution, and has some antiseptic properties. Holocain should not be used hypodermatically. The bottle should be washed out with pure muriatic acid before a solution of holocain is put in it, otherwise a combina- tion with the trace of lead, always found in a new bottle, will take place. Eucain "B" has proven too irritating to supplant either of the above anesthetics in eye practice. Chloretone, anesin, acoin, stovaine, alypin, and novocain are new local anesthetics which possess no properties which especially recommend them. MYDRIATICS. Mydriatics are drugs which dilate the pupil. Cocain hydrochlorate may be used when a temporary dilation is required as, for example, for ophthalmo- scopic examinations. The eye must be kept closed while the pupil is dilating and too much cocain must not be used or a wrinkling of the epithelial layer of the cornea w411 prevent the examination. Cocain does not cause paralysis of the ciliary muscle, consequently vision is very slightly affected by its use. The pupil will return to its normal state in an hour or two. 220 LESSONS ON THE EYE. Euphthalmin hydrochlorate is very similar in its my- driatic action to cocain . It does not dry out the corneal epithelium or paralyze the ciliary muscle. ■ Euphthal- min is used in a five per cent, solution. Ephedrin hydrochlorate is recommended as a useful mydriatic which will dilate the pupil without causing paralysis of accommodation. It is used in a five per cent, solution. MYDRIATICS AND CYCLOPLEGICS. A cycloplegic is a drug which causes paralysis of the ciliary muscle and resulting suspension of accommo- dation. All of the cycloplegics are also mydriatics. Homa tropin hydrobromate is a satisfactory mydriatic. Its effect upon the pupil is more lasting than that of cocain or euphthalmin. For mydriasis one grain to the ounce is sufficient. When homatropin is used as a cycloplegic, in testing for refractive errors, the mistake is often made of using it too weak. The following pre- scription, freshly made, will produce total cycloplegia. I^ Homatropin hydrobromate . . . .gr. i. Aq. distill OSS. SiG. — One drop in each eye every ten minutes, for one hour. Thirty minutes after the last drop the patient is ready to examine. The effect will wear oft' in about thirty-six hours. Atropin sulfate is the most powerful mydriatic and cycloplegic. A one per cent, solution is usually em- ployed. Its effect will not disappear for about ten days, GENERAL THERAPEUTICS. 221 therefore it must not be used thoughtlessly on those who need their near vision. It is used when total inac- tivity of the ciliary muscle or wide dilation of the pupil is desired. Atropin is the active principle of belladonna and caution must be observed in its use as some individuals manifest a pronounced susceptibility to belladonna poison. Duboisin sulfate (gr. 1/4 to gi.), hyoscyamin hydro- bromate (gr. 1/4 to ^i.), scopolamin hydrobromate (gr. 1/8 to 5ii.), and daturin sulfate (gr. 1/8 to 5i.) are cycloplegics whose action and use are about the same as atropin. Their effect wears off in from four to seven days. The use of a mydriatic has brought on glaucoma in the manner described on page 179. For this reason tension of the eye should be noted and great caution observed before their use, particularly in elderly people. MYOTICS. Myotics contract the pupil and increase accommoda- tion by stimulation of the ciliary muscle. Eserin sulfate or salicylate is the most powerful of the two myotics and is used in strength varying from gr. 1/20 to gr. ii.to oi-. depending upon the object to be attained. The w^eakest dose is used for the purpose of stimulating accommodation and the strongest in glau- coma, page 181. Eserin solutions become pink when kept for any length of time ; this does not indicate any deterioration in strength. Pilocarpin hydrochlorate is much weaker than eserin and is used only when feeble action is desired. Grain i. to §i. is the strength generally used. It is also used 222 LESSONS ON THE EYE. hypodermatically to produce diaphoresis, for example, in detachment of the retina and in choroiditis. ANTISEPTICS AND DISINFECTANTS. It has been demonstrated that the thorough mechani- cal cleansing of the conjunctival sac with sterile water or normal salt solution is as successful a method of asepticizing it as the use of the chemical antiseptics. Antiseptics cannot be used freely in strong solutions ow4ng to the danger of irritating the conjunctiva and injuring the cornea. The strength employed will depend upon the object to be attained. The same antiseptic may be used in a weak solution to remove secretion from the conjunctival sac, in a concentrated form to disinfect a corneal ulcer and in an intermediate strength as an application to the palpebral conjunctiva. Formalin, i to 6,000 solution, may be used in the con- junctival sac. As a disinfectant, applied directly to a corneal ulcer, on a cotton applicator, i to 100 may be used. Trikresol is one of the least irritating antiseptics. A solution of I to 1,000 makes a valuable menstruum for eye drops as bacteria will not develop in it. Peroxid of hydrogen is exceedingly painful. It is used to disinfect corneal ulcers, but holocain anes- thesia should precede it. Bichlorid of mercury should not be stronger than i to 5,000 if employed as a wash. It sometimes irritates in this strength. When appHed to a trachomatous lid it may be used as strong as i to 500, but its action must be limited to the part treated. GENERAL THERAPEUTICS. 223 Biniodid of mercury is used as a wash in Panas' solu- tion, as follows : Mercuric iodid gi"- i/7 Alcohol 5/i. Aq. destill. q. s o/^'^- Permanganate of potash solution is generally em- ployed in I to 2,000 strength. Pyoktanin (blue) in i to 2,000 solution is sujjposed to be an especially reliable antiseptic in purulent condi- tions of the lacrymal sac. Boric acid, gr. xii. to §i., is used as a cleansing wash and as a colly rium. In the latter case it is generally combined with other remedies. Its antiseptic proper- ties are quite limited. Borax, gr. iv. to §i., is similar in its application to boric acid. Carbolic acid is never used as a cleansing wash or as a collyrium. It is a popular disinfectant for corneal ulcers. When thus applied a local anesthetic must be used and great care observed to prevent the acid from spreading beyond the edge of the ulcer. Dip a lacry- mal probe in pure carbolic acid and let as much run off as will; what remains may be sufficient. It is better to repeat this process a number of times than to apply so much that it runs over the healthy cornea. Tincture of iodin is used in infected corneal ulcers the same as carbolic acid. Silver nitrate is an old and valuable disinfectant and astringent. The preparations of silver are probably the most useful remedies we have in the treatment of eye diseases. They are used as prophylactics, also in 224 LESSONS ON THE EYE. conjunctival inflammations when pus is present, in disease of the Hd border, in diseases of the lacrymal sac, and in ulceration of the cornea. One per cent, solu- tion of nitrate of silver is dropped into the eyes of in- fants to prevent ophthalmia neonatorum. In | to i per cent, strength it is applied to the palpebral con- junctiva. To disinfect ulcers of the cornea it is used in strong solution in the same manner as carbolic acid. The "mitigated stick" is composed of silver nitrate and potassium nitrate in various proportions. Protargol, a new organic salt of silver, is used in five to twenty per cent, solutions. It is not as irritating as silver nitrate and seems to be more efficient in some conditions. Argentamin, albargin and nargol are new silver prep- arations which have their advocates but there seems to be no reason why they should supplant protargol. Argyrol (silver vitelline) is a justly popular silver product. It is painless and non-irritating, contains thirty per cent, of silver, does not coagulate albumen and is said to have greater penetrating action than any of the other silver preparations. It is used in five to fifty per cent, solutions. The actual cautery is a most useful • disinfectant of corneal ulcers. STIMULANTS AND ASTRINGENTS. Copper sulfate crystal (" blue stone") is applied to the palpebral conjunctiva in trachoma and chronic con- junctivitis. The membrane should be touched lightly or rubbed with the crystal, depending upon the effect GENERAL THERAPEUTICS. 225 desired. The surface of the crystal must be abso- lutely smooth to avoid scratching the conjunctiva. It is sometimes employed in solution of one-half grain to the ounce. Cuprol is an organic combination of copper and nucle- inic acid, containing about six .per cent, of metaUic cop- per. The ten per cent, solution is generally used in conjunctival diseases. Alum is employed in chronic conjunctivitis in the crystal form or in a solution containing from one-half a grain to two grains to the ounce. Tannin dissolved in glycerin in the proportion of one part of tannin to eight of glycerin is sometimes applied to the palpebral conjunctiva in trachoma. It is also recommended in phlyctenular conjunctivitis. Zinc sulphate is used in coUyria, in strength varying from one to two grains to the ounce. It is of special value in diplo-bacillus conjunctivitis. Zinc chlorid, grain one to the ounce, is also very use- ful in this disease. Boroglycerid (U. S. P.) is applied to the everted Hd in trachoma and chronic conjunctivitis. Camphor water, a weak stimulent and astringent, is used in coUyria. One part of camphor water to three of distilled water makes a good menstruum for stronger astringents. POWDERS. Powders must be triturated as thoroughly as possible before being dusted upon the cornea or used in an ointment in the conjunctival sac. 15 226 LESSONS ON THE EYE. Calomel is dusted upon the cornea in cases of corneal ulceration, pannus, and phlyctenular ophthalmia. It should not be used when an eye is in a state of active inflammation or when the patient is taking iodids internally, see page 135. Iodoform is used in corneal ulceration. It may be applied as a powder or in an ointment. It sometimes produces severe irritation if care is not observed in the selection of the preparation used. Xeroform and nosophen are antiseptic powders which are recommended in the treatment of corneal ulceration. OINTMENTS. Yellow oxid of mercury is employed in the form of an ointment made with vaselin, cold cream, or lanolin. When it is to be used in the conjunctival sac it will mix better with the tears if albolene is incorporated. The ointment should be rubbed until not a grain of mercury can be seen. One per cent, is the usual strength, but it may be made stronger or weaker. It is used in dis- eases of the lids, conjunctiva, and cornea as described under these subjects. It should not be -exposed to the light. Ammoniated mercury is indicated in the same con- ditions and is employed in the same strength as the yellow oxid. Boric acid, one grain to the dram of vaseHn, is a bland ointment which may be used on the border of the lids to prevent them from sticking together when secretion is excessive. GENERAL THERAPEUTICS. 227 MISCELLANEOUS REMEDIES. Jequirity is used to establish an acute membranous conjunctivitis in trachoma and pannus. It seems to have a decidedly beneficial influence in selected cases. Twenty grains of the decorticated beans are ground, then put in an ounce of cold water and allowed to stand for twenty-four hours. The palpebral conjunctiva is painted with this infusion and in a few hours active inflammation sets in. In' a few days the inflammation subsides and gradual improvement of the ]3annus follows. Jequiritol, a preparation sold by Merck, with full instructions for its use, is said to be safer and more reliable than the infusion of jequirity beans. Suprarenal extract will produce a thorough hcmostasis of the conjunctiva. Tenotomies, pterygium opera- tions, etc., are rendered practically bloodless by its use. Adrenalin chlorid and suprarenalin are preparations of the gland which may be used in strength varying from 1 : 5,000 to 1 : 20,000. The value of suprarenal extract as a therapeutic agent is limited. It should not be used in glaucoma. Dionin is a morphin derivative used generally in a two to five per cent, solution. It causes pain when instilled into the conjunctival sac and should be preceded by a local anesthetic. It is a lymphagogue and a few min- utes after its application a decided conjunctival edema appears. It is of decided value in relieving the pain of glaucoma, iritis, and iridocyclitis. It is said to in- fluence the absorption of the post-operative debris of cataract. In dionin we undoubtedly have a valuable 228 LESSONS ON THE EYE. analgesic. In addition to its above uses it has been rec- ommended for sub-con junctival hemorrhage hy- phema, interstitial keratitis, vitreous opacities, scleritis, episcleritis, and ulceration of the cornea. Fluorescin is used to determine the area of the cornea which is denuded of its epithelium by ulceration or traumatism. A drop of the following solution placed upon the cornea will stain green all tissue not covered by epithelium. Fluorescin gi". i. Sodii bicarb gr. ii. Aq. destill 5 ii- Ichthyol, in a 25 to 50 per cent, solution, has been used in conjunctival affections. It has been recom- mended for marginal blepharitis, in a ten per cent, ointment. Ichthalbin is proposed as a substitute for ichthyol as it is free from the disagreeable odor of the latter. The Roentgen ray has been used with success in cases of epithelioma and rodent ulcers of the lids. It seems of definite value in trachoma. It is also recom- mended for vernal catarrh and episcleritis. Radium has been used in rodent ulcers, trachoma, episcleritis, and corneal opacities. It is said to have analgesic properties in cases of painful uveitis. Sub-conjunctival injections of salt solution and solu- tions of mercury have been used for corneal ulceration, interstitial keratitis, all forms of uveitis, vitreous opaci- ties, and detachment of the retina. One drop of one per cent, solution of acoin should be added to the injected fluid to diminish the pain. The amount of GENERAL THERAPEUTICS. 229 fluid advised varies from a few drops to a syringeful. The physiologic salt solution is probably as efficacious as the mercury solutions, and is not as liable to pro- duce inflammatory adhesions of the sub-conjunctival tissues. The sub-conjunctival injection of sterilized air has been used as a satisfactory substitute for the above solutions. Intra-muscular injections of mercury seem to yield better and quicker results than the older methods. They have been used in optic neuritis, progressive optic atrophy, uveitis, sympathetic ophthalmia, and central chorio-retinitis as well as in the usual syphilitic manifestations. One-fifth of a grain of hg. succinimid is the dose of the most popular preparation. Serum therapy and vaccine therapy are engaging the attention of many investigators. Their value as therapeutic agents in the treatment of eye disease has not yet been definitely established. INDEX Abducens nerve, 2, 6 paralysis of, 60 Abrasion of the cornea, 140 Abscess of the lacrymal gland, 88 of the lacrymal sac, 90 of the orbit, loi Absolute glaucoma, i 78 Accommodation, 46 in glaucoma, 176 in hyperopia, 53 Acetate of lead in follicular conjunc- tivitis, 122 Acid burns, 1 2 7 Acoin, 219 Actual cautery, 224 Acute trachoma, i 20 Advancement of an ocular muscle, 65 , 69, 71 Albargin, 224 Albinism, 72, 165 Albuminuric retinitis, 197 Alcoholic amblyopia, 205 Alternating strabismus, 67 Alum, 22s Alypin, 219 Amaurosis, 210 partialis fugax, 212 Amblyopia, 210 central, 204 congenital, 210 from alcohol, 205 from carbon bisulfid, 206 from quinin, 206 from tobacco, 205 hysterical, 21 1 simulated, 2 1 1 with strabismus. 68 Ametropia, 52 Ammoniated mercury, 226 Anemia of the retina, 191 Anesin, 219 Anesthesia by cocain, 2 1 8 by holocain, 219 general, 218 local, 218 of the cornea, 140, 148, 178 Anel's syringe, 94 Aneurism in the orbit, 104 Angioma, 129 Angle of the anterior chamber, 20 Anisometropia, 58 Ankyloblepharon, 80 Anomalies of the puncta and canaliculi , 89 Anterior capsule of the lens, 29 chamber, 13, 20 ciliary arteries, 18, 22, 27 polar cataract, 185 pole of the eyeball, 1 5 synechia, 137, 145 Antimetropia, 58 Antiseptics, 222 Antitoxin, 1 1 4 Aphakia, 190 Apoplexy, pupil in, 152 Aqueous chamber, 13, 22 humor secreted and excreted, i 74 Arachnoid sheath of the optic nerve, 32 Arcus senilis, 146 Argentamin, 224 Argyll- Robertson pupil, 152, 208 Argyria, 108 Argyrol, 224 Arteria centralis retinae, 30 Arterial pulsation in glaucoma, 177 Associated movements of ocular mus- cles, S9 Asthenopia, 70 Astigmia, 56 Astringents, 224 Atrophy of the ball, 172, 179 of the optic nerve, 208 231 232 Atropin sulfate, 220 in iritis, 156 in corneal ulceration, 141 Axis of the eyeball, 14 Bacillus of diphtheria, 113 Balance of the eye muscles, S9 Bichlorid of mercury, 222 Biconcave lenses, 42 Biconvex lenses, 42 Binasal hemianopsia, 213 Biniodide of mercury, 223 Binocular field of vision, 49 Bitemporal hemianopsia, 213 Black eye, 85 Blennorrhea, chronic conjunctival. Blepharitis, 73 Blepharospasm, 81 Blindness, simulated, 211 Blood vessels of the choroid, 26 of the eye, 3 of the iris, 22 of the retina, 30 Borax, 223 Boric acid, 223, 226 Boroglycerid, 225 Bowman's membrane, 1 s probes, 92 Brain, tumor of, 204 Bright's disease, 197 BuUer's shield, 1 1 1 Burns by acids, 127 by lime, 127 by powder, 126 Calomel, 226 in interstitial keratitis, 13s in phlyctenular keratitis, 132 Camphor, 225 Canal of Cloquet, 29 of Schlemm, 19, 151 the hyaloid, 29 Canaliculus, anatomy of, 10 obstruction of, 90 Canthotomy, 1 1 1 Canthus, external and internal, 8 Capsule of the lens, 28 of Tenon, 3 inflammation of, 103 CarboHc acid, 223 Carcinoma, 86, 173 Caries of the orbit, 99 Carotid ligation and compression of, 104 Caruncle, n Cataract, 185 anterior polar, 185 cortical, 187 lamellar, 186 nuclear, 187 posterior polar, 186 Catarrhal conjunctivitis, 105 chronic, 107 Cautery, 140, 194 Cellulitis, orbital, loi Centrad of Dennett, 38 Chalazion, 75 Chemosis, 109 Chiasm, 33 Chloretone, 219 Choked disc, 203 Chorio-capillaris, 27 Choroid, anatomy of, 25 diseases of, 165 Choroiditis, 165 central, 168 disseminate, 167 exudative, 165 myopic, 169 plastic, 1 6s purulent, 171 syphilitic, 168 Cilia, 8 Ciliary arteries, 22, 26, 27 body, anatomy of, 22 diseases of, 158 ganglion, 24 muscles, 22 nerves, 22 processes, 22 Circulus arteriosus iridis major, 22 minor, 22 Circumcomeal injection, iS4 Cocain hydrochlorate, 218, 219 Cold applications, 106, no, 217 Color blindness, central, 204 congenital, 50 perception, 49 Color of the iris, 1 9 Commissure, optic, 33 Concave lens, 41 Concavoconvex lens, 42 Comitant strabismus, 66 Congenital amblyopia, 210 cataract, 185 233 Congenital color blindness, so Conical cornea, 147 Conjugate foci, 40 Conjunctiva, anatomy of, 10 diseases of, 105 Contraction of the pupil, 152 Convergence, 47 Convergent strabismus, 67, 70 Convex lens, 39 Convexoconcave lens, 42 Copper sulphate, 224 Cornea, anatomy of, i s diseases of, 130 Cortex of the lens, 29 Cortical cataract, 187 Cover test, 70 Crab lice, 85 Crede's method. 1 1 2 Crossed diplopia, 63 Croupous conjunctivitis, 1 1 2 Crystalline lens, anatomy of, 28 diseases of, 1 84 Cuneus, 34 Cuprol, 22s Curvature of the cornea, 56 Cyclitis, 158 Cyclodiallsis, 181 Cycloplegics, 220 Cylindric lens, 42 Cysts of the conjunctiva, 129 Dacryocystitis, acute, 94 chronic, 90 Dacryops, 89 Daturin sulfate, 221 Day blindness, 215 Decussation of the optic nerves, 33 Degenerative changes in glaucoma, 1 79 Deposits on the cornea, 157 Dermoid tumors, 129 Descemitis, 156 Descemet's membrane, 1 7 Desmarre's elevators, no Detachment of the retina, 200 Deviating eye, 60 Diagnostic table, 182, 183 Dilatation of the pupil, 152 Dionin, 227 Diopter, 44 Diphtheritic conjunctivitis, 1 1 2 Diplo-bacillus of Morax and Axenfeld, 106, 141 Diplopia, 61, 67 Disinfectants, 222 Dislocation of the lacrymal gland, 89 of the lens, 184 Divergent strabismus, 67 Double vision, 61 Duboisin sulfate, 221 Dural sheath of the optic nerve, 32 EccHYMOsis of the lids, 8s sub-conjunctival, 128 Ectropion, 78 Eczema of the lids, 84 Eldridge-Green theory, s i Electric ophthalmia, 191 Electrolysis in trichiasis, 77 Elevators, Desmarre's, iio Embolism of the retinal artery, 192 Emmetropia, 45 Emphysema of the lid, too Encephalocele, 97 Endothelium of the cornea, i 7 Entropion, 78 Ephedrin hydrochlorate, 220 Epilation, 77 Epiphora, 73, 87 Episclera, the 18 Episcleritis, 149 Epithelioma, 86, 129 Epithelium of the cornea, 15 Equator of the ball, 1 5 of the lens, 29 Equilibrium of the ocular muscles, S9 Erysipelas of the lids, 86, 102 Eserin, 221 in glaucoma, 181 Esophoria, 70 Esotropia, 67 Eucain, 219 Euphthalmin hydrochlorate, 220 Eversion of the punctum, 89 Excavation of the disc, 177 Exciting eye, iS9 Exclusion of the pupil, IS3 Exophoria, 70 Exophthalmos, 98 Exostosis, 100 Exotropia, 67 External canthus, 8 ophthalmoplegia, 60 palpebral ligament, 6 234 INDEX. External rectus muscle, 3 Eyeball, anatomy of, 1 2 Facial nerve, 6 paralysis of, 82 False image, 62 Far sight, 52 Field of vision, 48, 176, 199 Fifth nerve, 2, 12. 15 Fistula of lacrymal sac, 95 Fixing eye, 60 Fluorescin, 228 Focal distance of a lens, 40 Follicular conjunctivitis, 121 Fontana, spaces of, 21, 174 Foreign body in the cornea, 147 in the eyeball, 161 in the vitreous, 164 Formalin, 222 Fornix, conjunctival, 1 2 Fourth nerve, 2, 6 Fovea centralis, 30 Fulminating glaucoma, 1 78 Fusion faculty, 69 Galvano cautery, 140, 224 Ganglion, the ciliary, 24 Glands of Moll, 8 Glaucoma, 174 Glioma of the retina, 201 Gonococcus of Neisser, 109 Gonorrheal conjunctivitis, 108 Granular conjunctivitis, 115 Gumma of the iris, 154 Halos around lights, 176 Head, position of in strabismus, 64 Headache, 64, 70 Hemeralopia, 215 Hemianopsia, 213 Hemorrhage, intra-ocular, 163, 173, 180, 198 Herpes zoster ophthalmicus, 84 Heteronymous diplopia, 63 Heterophoria, 69, 70 Holocain hydrochlorate, 219 Homatropin, 220 Homonymous diplopia, 63 hemianopsia, 213 Hordeolum 74 Horner's muscle, 2, 6 Hot applications, 217 Hutchinson's teeth, 134 Hyaloid artery, 29 canal, 29 fossa, 28-29 membrane, 29 Hyoscyamin hydrobromate, 221 Hyperemia of the conjunctiva, 105 of the retina, 191 Hyperopia, 52, 67 Hyperostosis, 100 Hyperphoria, 70 Hypertropia, 67 Hypopyon, 138 Hysterical amblyopia, 211 blepharospasm, 81 Iced compresses, 106, no Ichthalbin, 228 Ichthyol, 228 Illumination, oblique, 148 Image, real and false, 62 Inferior rectus muscle, 3 oblique muscle, 4 Infiltration of the cornea, 130, 133, 137 Infra-orbital foramen, 2 groove, 2 Injection, ciliary, 154 conjunctival, 105 Injuries of the orbit, 100 Insertion of the recti muscles, 4 Insufficiency of ocular muscles, 69 Internal canthus, 8 ophthalmoplegia, 60 palpebral ligament, 6 rectus muscle, 3 Interstitial keratitis, 132 Intra-ocular tension, 174 muscular injections, 229 Iodoform, 226 Iridectomy, 144, 180 Iris, anatomy of, 19 diseases of, 152 Iritis, plastic, 153 serous, 136 suppurative, 156 Isometropia, 58 Jequirity, 227 use of, in pannus, 119, 144 Jequiritol, 227 Jews, predisposition to trachoma, ii8 Jonnesco's operation, 180 235 Keratitis, interstitial, 132 phlyctenular, 130 punctate, 156 vascular, 143 Keratoconus, 147 Klebs-Loffler bacillus, 113 Knapp's trachoma forceps, i 20 Lacrymal apparatus, anatomy of, 9 diseases of, 87 gland, 9 dislocation of, 89 fistula of, 89 sac, I, 10 fistula of, 95 Lagophthalmia, 82 Lagrange's operation, 180 Lamellar cataract, 1 86 Lamina cribrosa, 18 basilis, 27 fusca, 19. 2S vasculosa, 26 Latent squint, 69 Lens, crystalline, anatomy of, 28 diseases of, 184 Lenses, concave, 41 convex, 39 cylindrical, 42 Lenticular astigmia, 5 7 ganglion, 24 Leucoma, 144 Levator palpebne supcrioris, s Lice, crab, 85 Lid clamp, 76, 85 speculum, 190 Lids, anatomy of, 6 diseases of, 73 Ligamentum pectinatum, 20 Ligation of the common carotid, 104 Light. 35 rays. 35 Light, perception in cataract, 189 Lime bums, 127 Lipoma, 129 Locomotor ataxia, 152 Long ciliary arteries, 22, 27 nerves, 24 Lupus of the lids, 86 Lymph spaces of the cornea, 1 7 Macula lutea, 30 of the cornea, 144 Malingering, 21 1 Massage of the cornea, 13s Megalopsia, 166, 195 Meibomian glands, 8 Membrane of Bowman, 15 of Descemet, i 7 Membranous conjunctivitis, 112 Meningocele, 97 Meridians of the eyeball, 15 Metamorphopsia, 166, 195 Micropsia, 166, 195 Milium, 86 Miner's nystagmus. 72 Mixed trachoma, 116 Moll's glands, 8 MoUuscum contagiosum, 86 Monolateral strabismus, 67 Morbid growths in conjunctiva, 128 MuUer's muscle, 55 Musc;e volitantes, i6i Muscles, ocular, 3 Muscular equilibrium, S9 Mydriasis, 152 Mydriatics, 152, 219, 220 Myopia, S4, 68 Myopic crescent, t 70 Myosis, 152 Myotics, 152, 221 Nargol, 224 Nausea in paralytic strabismus, 64 Nasal duct, 10 stricture of, 91 Nebula of the cornea, 144 Necrosis of the orbit, 99 Negative focus, 41 Nerve, optic, 31, 203 Nerves of ocular muscles, 6 Neuro-paralytic keratitis, 139 Neuro-retinitis, 194. 204 Nevus, 86, 129 Nictitation, 81 Night blindness, 199, 214 Nosophen, 226 Nuclear cataract, 187 Nucleus of the lens, 29 Nyctalopia, 214 Nystagmus, 71 OBLiyuE illumination, 148 muscles, 4 position of head in squint, 64 236 Obliteration of the puncti,' 90 of lacrymal sac, 96 Occlusion of the pupil, 153 Ocular muscles, 3 Oculomotor nerve, 6 Opacity of the comer, 144 of the vitreous, 162 Ophthalmia neonatorum, 108 Ophthalmic artery, 3 vein, 2 Ophthalmoplegia, external, 60 internal, 60 total, 60 Optic commissure, 33 Optic disc, 30, 31 foramen, 2 nerve, 2, 31, 203, 208 tracts, 33 Optics, 35 Ora serrata, 30 Orbicularis muscle, i , 6 Orbits, anatomy of, i diseases of, 97 Orbital cellulitis, loi Orthophoria, 70 Outer canthus, 8 Palpebral fissure, 8 Pannus 117, 143 Panophthalmitis, 139, 171 Papilke of conjunctiva, 1 1 Papillary trachoma, 115 Papillitis, 203 Papilloma, 129 Parallel rays, 45 Paralysis of ocular muscles, 60 Paralytic ectropion, 78 strabismus, 60 Parenchymatous keratitis, 132 Paresis of ocular muscles, 60 Pectinate ligament, 20 Perception of colors, 49 Perforation of the cornea, 137 Perichoroidal space, 19 Pericorneal injection, 154 Periostitis, 97 Periostosis, 100 Permanganate of potash, 223 Peroxide of hydrogen, 222 Phlyctenular conjunctivitis, 130 keratitis, 130 Phthiriasis, 85 Phthisis bulbi, 172, 179 Physiology of the eye, 45 Pial sheath of the optic nerve, 32 Pilocarpin hydrochlorate, 221 Pinguecula, 125 Planoconcave lenses, 42 convex lenses, 42 Plica semilunaris, 11 Position of eye in the orbit, 1 2 Posterior chamber, 13, 21 ciliary arteries, 1 8 nerves, 18 polar cataract, 186 pole of eyeball, 15 staphyloma, 170 synechia, 134, 153 Powder burns, 126 Presbyopia, 47 Primary colors, 50 deviation of squinting eye, 61 Principal axis of a lens, 40 focus of a lens, 40 Principal meridians of cornea, 57 Prism diopter of Dennett, 38 Prisms, 38 Probes for nasal duct, 92 Proliferative uveitis, 160 Proptosis, 98 Projection of retinal images, 62 Protargol, 224 Pseudo-glioma, 171, 202 Pterygium, 124 Ptosis, 82 Pulsating exophthalmos, 104 Puncta lachrymalia, 10 Pupil, 19, 152 Pupillary adhesions, 153 Purulent conjunctivitis, 108 Pus in the anterior chamber, 138, 154 Pyoktanin, 223 Qumm amblyopia, 206 Radium, 228 Rays of light, 35 Real image, 62 Recti muscles, 3 Refracting media of the eye, 45 Refraction, 35-45 Retina, anatomy of, 30 diseases of, 191 Retinitis, 194 INDEX. 237 Retinitis, albuminuric 197 diabetic, 197 hemorrhagic, 198 pigmentosa, 199 serous, 194 syphilitic, 198 Retro-bulbar neuritis, 203, 204 Roentgen ray, 228 Rupture of the choroid, 173 Sarcoma, 86, 129, 173 Schlemm's canal, 19, 174 Sclera, anatomy of, 18 diseases of, 149 Scleritis, 150 Sclerotomy, 180 Scopolamin hydrobromate, 221 Scotoma, 165, 176, 204, 212 Scrofulous conjunctivitis, 131 Second sight, 188 Secondary deviation in squint, 61 Semilunar fold, 1 1 Septum orbitale, 8 Serous iritis, 156 cyclitis, 158 Serum therapy, 229 Short ciliary arteries, 26 nerves, 24 Short sightedness, S4 Silver nitrate, 223 Simple colors, 50 Simulation of blindness, 211 Sixth nerve, 2, 6 SHtting of canaliculus, 92 Snow blindness, 191 Spaces of Fontana, 21, 174 Spasm of the orbicularis, 81 Sphenoidal fissure, 2 Spheno-maxillary fissure, 2 Spheric lenses, 39 Spring catarrh, 123 Squint, 60 Staphyloma, 139, i45. iSi. '70 Stovaine, 219 Strabismus, paralytic, 60 comitant, 66 Stricture of the nasal duct, 91 Stye, 74 Subarachnoid space, 33 Subconjunctival ecchymosis, i 28 injections, 228 Subdural space, 32 Substantia propria of cornea . 1 5 Superior oblique muscle, 4 rectus muscle, 3 Suprachoroidea, 25 Supra-orbital foramen, 2 -renal extract, 227 Symblepharon, 126 Sympathetic nerve, 20 ophthalmia, 158 Sympathizing eye, 159 Synchisis of vitreous, 162 Synechia, 137, 138. i4S. i53 Syphilitic retinitis, 198 ulcer of conjunctiva, i 28 ulcer of lids, 86 Tannik, 22s Tarsorrhaphy, 82 Tarsus, anatomy of, 6 Tears, secretion of, 87 Tenon's capsule, 3 Tenotomy, 65, 69, 71 Tension, intra-ocular, 174 Tensor tarsi, 2, 6 Tests for malingerers, 211 Third nerve, 2, 6, 19 Thrombosis of retinal vein 102 of sinuses, 86 Tincture of iodin, 223 Tobacco amblyopia, 205 Tonic spasm of orbicularis, ."^i Total ophthalmoplegia, 6c Trachoma, 1 1 5 acute, I 20 Trichiasis, 77 Trikresol, 222 True image, 62 Tuberculosis of the conjunctiva i 79 of the choroid, 173 Tumors of the orbit, 103 Turbidity of the aqueous humor 154 Ulceration of the cornea, 136 Uveal tract, 13 Vaccine therapy, 229 Vascular keratitis, 143 Vena; vorticosi", 18, 27 Vernal conjunctivitis, 123 Vertigo in paralytic squint, 64 Virtual focus, 41 =38 Vitreous humor, anatomy of, 29 diseases of, 161 hemorrhage, 163 Week's bacillus, 106 Whooping cough, 128 Winking, habit of, 8i Xanthelasma, 86 Xeroform, 226 Xerosis bacillus, 75 • X-ray, 86, 10 1, 164, 228 Yellow spot or macula lutea, 30 oxid of mercury, 226 Young-Helmholtz theory of color per- ception, so Zinc chlorid, 225 sulfate, 225 Zonula of Zinn, 29 Zonular cataract, 162 RETURN OPTOMETRY LIBRARY TO— ^ 490 Minor Hall -1 642-1020 LOAN PERIOD 1 2 : 3 4 ■5 ( D ALL BOOKS MAY BE RECALLED AFTER 7 DAYS RENEWALS MAY BE REQUESTED BY PHONE DUE AS STAMPED BELOW UNIVERSITY OF CALIFORNIA, BERKELEY FORM NO. 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